First thoughts on the Sanders single payer bill

The Sanders single payer starts the needed process of fleshing out how single payer as envisioned by its proponents, would work in the United States.  This is a needed step.  We must have a blueprint with which to assess viability, identify areas of concern, note critical omissions and evaluate feasibility and points of weakness.  The bill and the three page explainer can be downloaded from this link.
Emma Sandoe has the best initial take on the bill:

The bill, as I understand it, aims to create a model that is fairly close to Medicaid for all with Medicare branding. It assumes multiple trillions of dollars of new revenue every year as it is trying to just lay out the coverage side of the problem.

Now let’s dig into the weeds:

Everyone in the country would be covered.  There would be no cost sharing for non-pharmacy services. Small and limited cost sharing would be in play for brand name prescription drugs. Regular medical care, preventative care, dental, vision, mental health and long term care would be covered.  Reproductive health care would be “comprehensive”.

Coverage would be based on a modification of the current fee for service system.  Private insurance contracts that cover the same services as the Universal Medicare system would be banned.  Service contracts would be allowed but as soon as a medical service provider receives a single dollar from one of these contracts, they lose eligibility to receive any payments from the Universal Medicare system for a year.

It makes no mention of Health Sharing Ministries or the Tennessee Farm Bureau that both sell insurance like products that are not currently regulated as insurance.  Private direct primary care provider organizations still seem like they would be allowed and viable under the bill.  Non-covered service providers such as cosmetic surgery would also remain a viable business proposition. However most other private individual to provider transactions become economically non-viable.

Long term care would be a split program between the states’ Medicaid programs and the federal government.  There no mention of pediatric long term care financing.  I am assuming that it will be covered somewhere but I am not seeing it in the bill.

The bill addresses ERISA.  It prohibits ERISA regulated entities from issuing benefits that duplicate Universal Medicare benefits.  This basically wipes out employer sponsored insurance as a benefit and makes ERISA irrelevant as a regulating law except in the oddest of edge cases.

Transition is addressed.  The bill would be in full effect on the 4th January 1st after the bill is signed into law.  Kids would be covered in the on January 1st after the bill is signed into law.  Medicare for the old and the disabled would see immediate benefit enhancement with vision and dental coverage plus the elimination of cost sharing in the first year.  Medicare age eligibility decreases in each year until the program fully phases in on the fourth January after enactment.  There would be a transition fund equal to 1% of national health expenditures per year for five years to give transition assistance to people in the insurance industry who have to find new work.  The program would be run at the regional and state level so there would be some new jobs there.

I have several major concerns for this bill.  I don’t understand where the money is coming from. The prescription drug elements of the bill seems to conflict with other parts of the law.   I don’t agree with the level of trust in the Secretary of Health and Human Services that the bill uses.  I see de facto nationalization of most medical facilities given the payment structure and contract limitations.

The bill barely addresses financing.  Eliminating the ability of employers to offer insurance effectively captures almost all of the lost revenue form the favored tax treatment of insurance premiums as theoretically wages should roughly increase at the same magnitude.  There are some intergovernmental transfers that will provide some funding.  But there is a funding gap that I am incapable of estimating beyond the language of my five year old in assessing how tall the buildings around him are.  The hole is either very big or super, super huge.

Section 201 says the standard for payment will be “medically necessary and appropriate”.  Section 202 forbids most cost sharing but does allow some prescription drug cost sharing:

(2) set a cost-sharing schedule for prescription drugs and biological products that encourages the use of generic drugs, provided that any such cost sharing does not apply to preventive drugs.

Section 614 states that the Secretary shall negotiate pharmaceutical prices annually.  Furthermore, the formulary should encourage generic drugs first.  Finally the formulary should discourage “the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.”

I have two major questions on how these sections work together.  Can the HHS Secretary say no?  For classes of drugs that are clinical substitutes such as Harvoni and Sovaldi for Hep-C genotype 1, can the Secretary credibly say “We’re buying one of these pills as the first line treatment, make me your best offer….” And then go with only one treatment regime?  If so, then the cost savings are real.  Yet, Section 201 has a medically necessary and appropriate standard that seems to invite at best only an effectiveness and not a cost-benefit standard towards inclusion and payment.  If Section 201 dominates, negotiation is merely cost control window-dressing as Universal Medicare would not be able to say no to any first line treatments.

However Section 202 seems to imply that the only differential cost sharing allowed is for a two tier formulary of generic versus non-generic, not preferred brand and non-preferred brand or preferred specialty versus non-preferred specialty.  Section 614 formulary language implies an allowance to tier or withhold until failure some medications.   I consider pharmacy benefits a black box that I don’t understand well, but I have a hard time seeing how this works at a decent cost savings.

The phrase “Secretary shall….”  Is used twenty six times in the bill.  There is a lot of flexibility for the Secretary of Health and Human Services in the act.  Some of it is needed.  Other areas such as defining eligibility for non-permanent residents of the United States is at risk of an HHS run by someone like Tom Price instead of an HHS run by Sylvia Burwell.  I am surprised that for a messaging and dream bill that there is so many points of potential sabotage are addressed.  I would have written stronger Congressional guidelines into black letter law and then reduce the downside option space.

Finally, while this bill is on its face a coverage bill, it will have incredible changes on the provision of medical services as well as the organization of the medical economy.  The provision in 303-C-2-b that make it incredibly difficult for most doctors and facilities to accept non-Universal Medicare funding effectively means over the long run that the federal government could decide to limit competition by controlling the capital funding allocations built into the proposed fee schedule.  This element as well as other sections of the bill regarding provider credentialing, invites regulatory capture by incumbent providers.  A captured regulatory structure will reduce the number of medical providers and increase costs without concurrent increases in positive outcomes.  It would be a system that is prone to rent seeking behavior.

This bill is a needed attempt to explain how single payer goes from a slogan with one thousand different meanings to an actual system.  It hand-waves the financing of a system while primarily focused on the mechanics of benefit provision.  That is fine for a first step but even within this limited first step, I am having a hard time seeing how the bill produces the positive outcomes it wants to produce at an acceptable long run cost.

 

UPDATE AND DISCLAIMER: I commented on an intermediate draft of the proposal and talked through several areas of concern and improvement with members of Senator Sanders’ staff.






173 replies
  1. 1
    Amanda in the South Bay says:

    There would be a transition fund equal to 1% of national health expenditures per year for five years to give transition assistance to people in the insurance industry who have to find new work. The program would be run at the regional and state level so there would be some new jobs there.

    I understand that Authentic Leftists want to destroy the private medical insurance industry (and for good reason), but the practical political implications are that there’s going to be a shitload of people worried about their jobs, (especially if there’s a recession), and I’m under no illusion that leftier than thous will turn out in 2022 to stop the inevitable Republican backlash.

    Even in the ideal bizarro universe in which the Dems had enough progressive votes in 2010 to establish Sanders/Canadian style single payer, how is it a good idea to destroy a sector of the economy in doing so? ISTM there are real political costs to essentially outlawing the private med insurance industry.

    And saying people can compete for state jobs-that’s not going to work well. Its also not going to work well for people who just want to keep their current private coverage.

    ReplyReply
  2. 2
    gene108 says:

    Let it be out there and let its defenders defend it.

    I am not seeing how this will be the godsend its proponents think it is. A lot of people go for jobs in medical billing, for example, because there are not a lot of better options.

    When those jobs get eliminated, there will be a lot of laid off middle class people angry at the government for destroying their careers.

    ReplyReply
  3. 3

    Is this Sanders contribution to destroying any chance Dems have in 2018? Then he and wife can retire in a dacha paid by Putin.

    ReplyReply
  4. 4
    chopper says:

    interesting. I have to say, until we’re sure today’s GOP is kept away from the levers of power for at least a generation, this whole idea is pretty moot to me. but it would be nice to have a working one on paper when that comes to pass.

    ReplyReply
  5. 5
    Ohio Mom says:

    Funny how no one ever says of Bernie as they do of Hillary, “He lost, why doesn’t he go away already”?

    I don’t see the point of this exercise at all because it isn’t a starting point for discussion because who besides Bernie is particularly interested in this discussion at this moment? There are too many other fish frying that are about to burn so much they will be inedible.

    ReplyReply
  6. 6
    Cheryl Rofer says:

    I read those provisions and breathe a deep sigh of relief. It is hard to imagine how freeing not having to worry about insurance coverage and payments and navigating an unreasonable system could be.

    The governmental process is similar whether the issue is health care or nonproliferation. It’s one thing to have slogans and another to fashion the dreams into law. The latter is much harder, but the first has a lot of appeal. The Republicans took seven years to produce nothing. This is the start of producing something. Plus hearing about it will give people hope and start them thinking about what a great world it could be.

    Not that universal coverage or single payer will end all worries, but it would take an enormous one out of the system.

    As to finding new jobs, there will be some opening up in the governmental healthcare apparatus, but probably not as many as in the bloated insurance industry. Ultimately, it’s likely to improve US productivity and (dare I say) balance of payments.

    ETA: One of the ways it could be paid for is to tax the 1% fairly.

    ReplyReply
  7. 7

    @schrodingers_cat: No, I don’t think so.

    I think this is a good faith effort to try to explain how a big idea that is popular within a significant segment of the Democratic base would actually work.

    ReplyReply
  8. 8
    gene108 says:

    @Amanda in the South Bay:

    I understand that Authentic Leftists want to destroy the private medical insurance industry (and for good reason),

    Private insurance has two negatives. One is billing issues. The other is they say no to things, like not allowing a more aggressive treatment versus something more routine, when you know only the more aggressive treatment will help your condition.

    The second roll of private insurance will fall to the government and the government will get the backlash of four year old Jane Doe being denied the only life saving treatment for her because government bean counters wanted to do treatments on the cheap.

    ReplyReply
  9. 9
    narya says:

    And I wonder what happens to community health centers (FQHCs). It sounds like the 340b money would go away, which would dramatically alter the finances of FQHCs, especially the ones who serve people with HIV, hep c, some MH issues, etc. More than 26,000.000 people received care from an FQHC last year, so it’s a non-trivial question/population.

    ReplyReply
  10. 10
    Barbara says:

    I don’t see the point of outlawing private insurance even though I realize that it creates pockets of inequity, in geographic regions and between demographic groups. I have never thought that we as a nation are homogenous enough to adopt a monolithic single payer system for every age level and demographic group.

    I do see the point of superseding ERISA as it relates to a state’s efforts to implement health reform.

    Although I think no cost sharing is probably asking for moral hazard, I do think that the level of cost sharing being imposed on people right now is ridiculous and needs to change, but that change won’t come without different kinds of limits (PCP referrals, etc.)

    Finally, the Medicare and Medicaid programs have never been operated without significant infrastructure management by private insurers. I wish more people understood that.

    ReplyReply
  11. 11
    Barbara says:

    @Cheryl Rofer: What will happen is what happened after Medicare was enacted: the government issued an rfp for claims processing and other insurance support contractors. The world will be different but it actually won’t be that different for most people. Now, those who sell and underwrite will likely need to shift to different lines of insurance.

    ReplyReply
  12. 12

    @Cheryl Rofer: Regarding insurance industry jobs, and speaking as a former insurance industry cog, most of those jobs are fundamentally easy substitutes. My previous work as an analyst required company and industry specific deep knowledge but the core skill set is readily transferable to other industries. Customer service gigs are readily transferable. The Legal Department can walk down the street to a law firm and be hired in an afternoon. The actuaries are probably the most locked in people but the core skill set of describing probabilistic worlds mathematically is an attractive skill set. I don’t see the transition over several years being hideous for most people.

    That would be question #55 on my list of questions for single payer plans.

    ReplyReply
  13. 13
    Barbara says:

    @narya: Look, I understand that these sorts of questions will arise, but try to remember that what signaled to those of us in the trenches that health care reform would die in 1994 was when Daniel Patrick Moynihan, who did not oppose it, stood up on the floor of the Senate and insisted that the bill had to protect academic medical centers at all cost. Once you start going down the road of plucking out your favorite program or project, forget it, it’s all over. But really, this is just a fantasy at this point. This is a program that doesn’t look like Medicare at all.

    ReplyReply
  14. 14
    Quit now says:

    Ah, the Senator from Fantasyland chimes in. The Joe Lieberman from the left. The Jill Stein inside the henhouse.

    ReplyReply
  15. 15

    The bill, as I understand it, aims to create a model that is fairly close to Medicaid for all with Medicare branding.

    Well, that’s not bad. (Still reading through your details.)

    It assumes multiple trillions of dollars of new revenue every year as it is trying to just lay out the coverage side of the problem.

    So as we suspected it’s not a real bill.

    ReplyReply
  16. 16
    Cheryl Rofer says:

    @David Anderson: Should be no problem for actuaries. I have a couple of friends who are freelance actuaries, and they have all the business they can handle and more. As you say, it’s an attractive skillset.

    ReplyReply
  17. 17

    So…

    If I was on the universal coverage (as I would have to be, obviously) but I wanted to pay for a supplementary plan that, I don’t know, offered better terms on MRI’s since my family has a history of needing lots of MRI’s, not only would that plan be illegal, but no provider would accept it if they wanted to accept the universal coverage?

    Second, suppose I wanted a supplemental plan that covered a wider range of drugs? I know that in NHS-like systems they can be pretty restrictive on the drugs they cover for, for instance, quality-adjusted life years reasons. Would that be legal?

    ReplyReply
  18. 18
    Mary G says:

    Some journo needs to ask Hillary what she thinks about this bill. It sounds like Bernie’s unicorn and pony show. Hillary actually had a bunch of hearings back when and has more realistic goals. Also, too the Democrats have been way too passive on this issue. Why wait for Bernie to lead?

    ReplyReply
  19. 19
    RobertDSC-iPhone 6 says:

    Not interested in what that tax-dodging fraud has to say.

    I am disappointed that my Senator, Kamala Harris, has signed on to his nonsense.

    ReplyReply
  20. 20
    Another Scott says:

    Thanks for this. I agree with you. It looks like Bernie is still taking the same approach – he knows The Truth and The Way™ and anyone who doesn’t agree is In The Pocket of [x]™. :-/

    Has Sherrod Brown said specifically what he doesn’t like about it? All I’ve seen is that he’s working on building bi-partisan support for Medicare buy-in at 55.

    I agree that a national incremental approach is the only way this is going to happen. As huge as California is, even they are too small to have a universal healthcare system. I’m Ok with the party arguing back and forth about this for a while, but I hope it doesn’t become a litmus test. Honestly, there are much bigger and more important topics that need to be addressed in the run-up to this fall’s elections, and in the 2018 and 2020 elections – Equal Protection, The Rule of Law (and Respect for Norms), Voting Rights and Voting Access (and Redistricting), War and Peace, The Destruction of the Federal Government, The Looting of the Economy by the 0.01%, etc. Let’s talk about what a sensible universal care system should look like and how to get there, but we’re going to have to start over once we have the majority (because circumstances and what we know about needed changes in the PPACA will have changed). Don’t make it a litmus test that further divides us, and don’t lose sight of what’s happening right now.

    Cheers,
    Scott.

    ReplyReply
  21. 21
    Oatler. says:

    @Mary G: Pelosi already answered that: “Wouldn’t be prudent, stay the course, thousand points of light…”

    ReplyReply
  22. 22

    @Another Scott:

    I’m Ok with the party arguing back and forth about this for a while, but I hope it doesn’t become a litmus test.

    Too late!

    @RobertDSC-iPhone 6:

    I am disappointed that my Senator, Kamala Harris, has signed on to his nonsense.

    The senators considering a presidential who need the cred run all have.

    @Oatler.: Hillary would probably talk about the need to address funding and say something snarky about unicorns or abs.

    ReplyReply
  23. 23
    gene108 says:

    Also, what about the family of immigrants. John Doe wants to bring his elderly parents from Italy to here, so he can care for them. Even if they did not qualify for Medicare, the elderly parents can get private insurance.

    One of my mom’s friends is in her late 80’s. Her daughter moved to Vancouver. Canada denied her immigration status, because of some issue with providing coverage.

    ReplyReply
  24. 24
    dr. bloor says:

    This strikes me as a “first step” only in the sense that the logical next step would be to drop it in the shredder and try for something vaguely plausible given the structure of our economy.

    A campaign manifesto in the guise of “legislation.” Gives 2020 aspirants lefty cred and will keep the money funnel hooked up to Bernie’s bank.

    ReplyReply
  25. 25
    Bailey says:

    @Mary G:

    Some journo needs to ask Hillary what she thinks about this bill. It sounds like Bernie’s unicorn and pony show. Hillary actually had a bunch of hearings back when and has more realistic goals. Also, too the Democrats have been way too passive on this issue. Why wait for Bernie to lead?

    Why does anyone need to ask Hillary about this? Is she voting on it? Is she going to ever hold elective office again? Is she the leader of the Democratic party? Answer to all the above is “no.” Why not ask the other dozen Senators who have signed onto this? Their opinion is certainly more relevant.

    ReplyReply
  26. 26
    Jack the Second says:

    @David Anderson: I think the main hit, besides the disruption, stress, and uncertainty of your industry going away, is that the vast majority of your value, as someone who is has a generalist skill-set but has specialized in a particular industry/company, is your specialized knowledge, not your generalized skills. If you have to jump to a completely different industry, you might not be starting completely over as an entry-level employee, but you’re really not much more valuable than someone with a few years of experience. For some people, that will amount to a 20 year setback in pay and status. Add in that you’ll probably have higher fixed expenses than you did 20 years ago (a mortgage planned for at your previous pay grade, college for the sprouts) and you’re looking at a lot of people having holes blown below the water line in their retirement planning. Even for the people who immediately get jobs they qualify for.

    ReplyReply
  27. 27
    Barbara says:

    @Another Scott: California is not too small — Denmark, for instance, is not even half as big and manages to have a national health insurance program. The problem for California or any other state is that it does not have free hand. It lives within a federal system where federal tax payments account for 40% of outright medical expenditures, and heavily subsidize most of the rest through tax incentives. Even though California is big and spends a lot of its own budget on Medicaid and employee benefit plans for state and local employees, California would somehow have to shoehorn its reform measures to accommodate the reality that federal funding is tied to federal requirements and federal taxes. Replacing all that funding is simply not feasible, because its residents would still be paying taxes to the federal government.

    ReplyReply
  28. 28
    itstrue says:

    @narya: Depends on the reimbursement. FQHCs now get a pretty decent flat daily rate from Medicare, and better-than-most Medicaid terms. In all likelihood they’d see similar numbers under this arrangement, and with a lot less cost sharing, bad debt to chase, billing, etc. I think they could live without 340B since it’s usually not a huge revenue source, and many don’t even participate now. A lot of these questions are answered by asking what happens if there are few or no uninsured, who are a third to a half of FQHCs’ business right now.

    Ending 340B could end up being a nice bargaining chip for stronger pharma price controls, since it’d take a load off of manufacturers to no longer have to create differential pricing. I always thought it was a nuts idea to subsidize the safety net through rebates from drug manufacturers anyway. The biggest losers in ending 340B would be eligible hospitals that get a ton of rebates for expensive cancer drugs, and AIDS Drug Assistance Programs, which get almost half their revenue from 340B, and might be made obsolete altogether if everyone can afford their antiretrovirals.

    Community health center programs like our FQHCs exist in other countries that have universal coverage (like Canada) because access to care in underserved communities is still an issue. Regardless of how the care is paid for, it’s still tough to ensure that people can actually get the care they need in rural areas, or parts of the urban environment where getting to a specialist is challenging. Those are the issues that will be with us even under the most utopian changes to health care finance.

    Somewhat unrelated, I’d like to know how the market for physician services changes if you can see any specialist you want, compared to now, where there are prices and networks acting as gatekeepers to a large percentage of the population. Anyone know how, for example, a highly-respected cardiologist in Canada manages patient demand when everyone with a heart murmur shows up with the same insurance card? Is it just the wait times for the best doctors that control demand? Honest question.

    ReplyReply
  29. 29
    Mary says:

    @gene108:

    The other is they say no to things, like not allowing a more aggressive treatment versus something more routine, when you know only the more aggressive treatment will help your condition.

    I’m not an expert by any means, but it seems incredibly unlikely to me that government-run insurance will not do exactly the same thing, and in fact may be even more conservative in their approach to treatment.

    ReplyReply
  30. 30
    Barbara says:

    @RobertDSC-iPhone 6: Has she signed on to this initiative in particular? This is basically a Christmas tree for Sanders. However, the reality is that if you don’t start way over to the left, you are likely to end up much further to the right than you want. This also has the virtue of being easy to explain, unlike Obamacare. There’s lots I don’t like about it — most of it, in fact — but I am not going to be a complete naysayer. The point is to move the window.

    ReplyReply
  31. 31
    rikyrah says:

    Thanks again Mayhew

    ReplyReply
  32. 32
    But her emails!!! says:

    @Barbara:

    Probably more important is the fact that California doesn’t control it’s own borders. Even if it could wrangle all the health care spending it’s due from the Federal Government, there’s a big additional chunk of cash it would need to collect (effectively what every individual and corporation is spending towards insurance premiums). How does it do that without people and companies running for the exit? How does it deal with citizens from Alabama who stop by for medical treatment?

    ReplyReply
  33. 33
    Bailey says:

    @Jack the Second:

    I think the main hit, besides the disruption, stress, and uncertainty of your industry going away, is that the vast majority of your value, as someone who is has a generalist skill-set but has specialized in a particular industry/company, is your specialized knowledge, not your generalized skills. If you have to jump to a completely different industry, you might not be starting completely over as an entry-level employee, but you’re really not much more valuable than someone with a few years of experience. For some people, that will amount to a 20 year setback in pay and status. Add in that you’ll probably have higher fixed expenses than you did 20 years ago (a mortgage planned for at your previous pay grade, college for the sprouts) and you’re looking at a lot of people having holes blown below the water line in their retirement planning. Even for the people who immediately get jobs they qualify for.

    I don’t understand this line of argument. We want to maintain a bloated, expensive and often inefficient insurance system because of the people who work in the insurance industry?

    ReplyReply
  34. 34
    Barbara says:

    @Mary: The reality is that Congress finds it almost impossible to say no. Anyone working with the Medicare program knows full well how much waste and abuse is embedded into the system because Congress can’t bear to say no and is always forcing the agency to back down on a variety of initiatives intended to root out abuse. It’s a shock when Congress actually puts its foot down, as it did with reimbursement for imaging technology by forcing the useless and counterproductive physician payment commission to assume a utilization rate of 90% for imaging equipment in establishing prices. The track record of the commission was to keep decreasing it so that it was basically a huge boondoggle. Of course, Congress probably only did that because of counterpressure from radiologists. This is how Medicare works. As much as people dislike insurers, insurers aren’t constantly worried about reelection. They do need to be subject to a robust policy making and regulatory infrastructure so that they are doing what we ask with public funds.

    ReplyReply
  35. 35
    Barbara says:

    @But her emails!!!: Well, I classify that as a secondary problem, but yes, it’s a problem as well.

    ReplyReply
  36. 36
    dr. bloor says:

    @Bailey: Ultimately, it’s less an issue of “What will David do,” and more an issue of “what happens when 17% of the economy starts playing musical chairs?” This is going to have in impact in health care well beyond the insurance industry, and there will be ripple effects.

    ReplyReply
  37. 37
    Sloane Ranger says:

    What’s the rationale for abolishing private health insurance? Here in Britain we’ve had a private health insurance industry running alongside the NHS since the beginning.

    If you want a routine operation at a time to suit you – go private. If you want to make sure you’re sharing the waiting room with your own kind to people – go to Harley Street. If you want your own room and an a la carte menu – go to a private hospital. Also lots of people get it through their employer as a benefit. I was in the civil service and I paid about £10 a month for membership of Benedon (previously civil service and postal employees sanitorium society.)

    The only people in the UK who are against it are the Trots.

    ReplyReply
  38. 38
    tobie says:

    @Cheryl Rofer:

    ETA: One of the ways it could be paid for is to tax the 1% fairly.

    I don’t think taxing the top 1% alone would be enough to finance this bill. And this is precisely the issue that the GOP will demagogue henceforth. That is why they are eerily quiet right now. They’re waiting to air yet again their line about tax-and-spend liberals.

    The Swiss and German healthcare system would have worked better for the US but alas we will never go there.

    ReplyReply
  39. 39

    @But her emails!!!: @Barbara: IMO the biggest issues are, one, that the federal government, even if it were to grant a waiver, could just yank it, in anger or sorrow depending on the republican, the next time there was a republican president; and two, the whole “no federal money can be spent on covering women’s bodily autonomy” thing.

    ReplyReply
  40. 40
    But her emails!!! says:

    @Sloane Ranger:

    Exactly where above did you see any mention of abolishing private insurance?

    ReplyReply
  41. 41

    @But her emails!!!: @Barbara: IMO the biggest issues are, one, that the federal government, even if it were to grant a waiver, could just pull it, in anger or sorrow depending on the republican, the next time there was a republican president; and two, the whole “no federal money can be spent on covering women’s bodily autonomy” thing.

    (Trying again, guessing at blacklisted words)

    @But her emails!!!: “Private insurance contracts that cover the same services as the Universal Medicare system would be banned” is a de facto banning of private insurance.

    ReplyReply
  42. 42
    Bailey says:

    @dr. bloor:

    Ultimately, it’s less an issue of “What will David do,” and more an issue of “what happens when 17% of the economy starts playing musical chairs?” This is going to have in impact in health care well beyond the insurance industry, and there will be ripple effects.

    Agreed there will be ripple effects. There always are when there are disruptions. But we are an okay society without, say, travel agents or elevator operators or switchboard operators, etc. A single payer system (or some other type of universal coverage) will be vastly, vastly freeing for all other types of employment. The idea that we would not press forward because there is such bloated bureaucracy that needs maintaining is absurd.

    ReplyReply
  43. 43
    tobie says:

    @Mary G:

    Also, too the Democrats have been way too passive on this issue

    Amen. Evidently they had lots of ideas but couldn’t figure out for the life of them how to make a bold statement. This left a vacuum…as usual.

    ReplyReply
  44. 44
    But her emails!!! says:

    @Major Major Major Major:

    I stand corrected.

    ReplyReply
  45. 45
    Jim, Foolish Literalist says:

    @Mary G: Also, too the Democrats have been way too passive on this issue. Why wait for Bernie to lead?

    There are actually any number of proposals from Stabenow, Murphy, a House bill and a bill Brown is working on to expand Medicare by essentially creating a public option through buy-in. And there are, I believe, several less ambitious proposals to stabilize the marketplaces and protect Medicaid expansion. But Wilmer has convinced a loud and electorally significant number of voters, or eligible voters, that all we need is righteous (and loud) sloganeering for western Wisconsin, the Ohio River Valley, Pennsyltucky and West Virginia– to say nothing of affluent and would-be affluent suburbanites– to rise up in favor of a massive tax increase and huge disruption in their medical coverage.

    @Another Scott: but I hope it doesn’t become a litmus test.

    I fear it already has

    ReplyReply
  46. 46
    Sloane Ranger says:

    @But her emails!!!: What Mx4 said at 41.

    ReplyReply
  47. 47

    Excellent, Saint Sanders has handed an issue for Rs to demagogue on. I can see the Facebook memes from Russian bots. Your $$ are providing insurance to the refugee moochers.
    .@Major Major Major Major: What about non-citizens, what about international students or work visa holders, how will they be covered?

    ReplyReply
  48. 48
    Barbara says:

    @Major Major Major Major: A waiver for changes this profound would have to be statutory, although the statute could give HHS authority to review the waiver against specific criteria. Maryland has had a statutory waiver in place since the beginning of the DRG system for hospital reimbursement that has helped significantly in stabilizing the cost of insurance in Maryland. The agency has to review it to make sure that the hospital rates that Maryland charges do not result in payments than are higher than would have been paid out under the DRG system. That’s the kind of thing that California would need, at a minimum. It would also need a Hawaii style waiver related to ERISA.

    ETA: California is one of the few states that continues to pay for excluded reproductive services (i.e., abortion) out of its own funds.

    ReplyReply
  49. 49
    dr. bloor says:

    @Bailey:

    Agreed there will be ripple effects. There always are when there are disruptions. But we are an okay society without, say, travel agents or elevator operators or switchboard operators, etc. A single payer system (or some other type of universal coverage) will be vastly, vastly freeing for all other types of employment. The idea that we would not press forward because there is such bloated bureaucracy that needs maintaining is absurd.

    No argument there, although also implicit in the conversation about “What happens to Betty in billing” is the issue of political viability, i.e., “Is Betty’s congress critter really going to vote her out of her current job?” See also, e.g., “Bloat, Defense Industries.” A nation unable to even put the final nail in the coffin of Big Coal is probably lacking the political will to turn health care on its head.

    ReplyReply
  50. 50

    @But her emails!!!: @Sloane Ranger: it doesn’t make a whole lot of sense unless your goal is to destroy private insurance (many leftists see this as a goal as worthwhile as achieving universal coverage, or even a necessary part of any universal scheme), and your trust in the benevolence of HHS is close to absolute.

    ReplyReply
  51. 51
    Barbara says:

    @Jim, Foolish Literalist: I actually don’t know that he has convinced an electorally significant slice of voters, but I do agree that they are very loud.

    ReplyReply
  52. 52

    @Barbara: as david said yesterday(?) in a comment thread, federal single payer is probably a more realistic goal than state single payer.

    ReplyReply
  53. 53
    Bailey says:

    @dr. bloor:

    No argument there, although also implicit in the conversation about “What happens to Betty in billing” is the issue of political viability, i.e., “Is Betty’s congress critter really going to vote her out of her current job?” See also, e.g., “Bloat, Defense Industries.” A nation unable to even put the final nail in the coffin of Big Coal is probably lacking the political will to turn health care on its head.

    Good points. However, I think there are larger, better arguments for the economic boom that can happen as a result of 1.) employees not being tied to their jobs for the insurance plus 2.) employers not having to serve as de-facto insurance companies (making them non-competitive globally) to dwell on poor Betty.

    But that will take actually have a bold public conversation. And leaders willing to have it.

    ReplyReply
  54. 54
    narya says:

    @itstrue: The FQHC for which I work is a bit of a unicorn, it’s true–but we earn tens of millions in revenue each year because of 340b (24% of our patients are living with HIV). This has enabled us to expand into areas of the city that are very underserved, so it’s not like we’re just lounging on the profits. That also means that we’re less dependent on direct federal funding–but we also have very expensive patients; our cost per patient is about three times the national average for CHCs.

    Which is not to say that it can’t work; my original point is that the CHCs were built and are funded because people face barriers to care, both in rural and urban locations. If those barriers are removed, our reasons for being would have to evolve as well. And, really, there are things about the model (patients on the Board of Directors) that could also serve as examples for some of the changes to the system.

    ReplyReply
  55. 55
    Jim, Foolish Literalist says:

    @Barbara: in a crowded Democratic primary, or in a purple state mid-term when their demographic is one of those Sherrod Brown, maybe Claire McCaskill is going to want to turn out, I think their vote/absence could be significant. And their volume and histrionics can make for bad TV

    ReplyReply
  56. 56
    Barbara says:

    @schrodingers_cat: Look at it as a template or starting point and react to it that way. Don’t give up or give in to trolls or bots. The country of Canada lives with a system that looks virtually just like this. The first pieces of it that would likely go would be no cost sharing, and prohibiting private insurance. HOWEVER, Medigap operates under just this kind of prohibition — it can’t duplicate Medicare benefits. It has to offer something more (and even that is regulated), and Germany and France also both have a dual track system, in which private insurers offer things that are not covered by the basic benefit plans that are required to be in place under their national systems. Explaining it this way might help people understand it better — private insurance would operate to supplement basic benefits, but would not substitute for such benefits. So you could still customize your experience, but you would be guaranteed basic protection.

    ReplyReply
  57. 57
    Barbara says:

    @Jim, Foolish Literalist: I am just going to vent a little at this. A lot of bad things could happen. But doing nothing on that principle, which is what I guess I see, just guarantees that bad things will happen. I just can’t wring my hands. I can engage and criticize but I am tired of hand wringing.

    ReplyReply
  58. 58

    @Barbara: it sounds to me like you can’t have a plan that covers the same services in a different (including more comprehensive) way, which seems nuts.

    ReplyReply
  59. 59
    Jim, Foolish Literalist says:

    @Barbara: I don’t advocate doing nothing, though I am by nature a pessimist. I just wish all those rumored presidential hopefuls hadn’t jumped on the noisiest, and rickety*, bandwagon so early. I think the Stabenow and/or Murphy approaches are a better fit politically for the electorate as a whole, as opposed to the twitter wing of Democratic base. How hard is it to say “I’m intrigued by my good friend Bernie’s proposal, I certainly agree that health care is a right and we need to do everything we can to get to true universal coverage. I look forward to seeing the details of his proposal and the CBO score”

    * I’ll be thrilled to be proved wrong.

    ReplyReply
  60. 60

    @Barbara: just because you or I haven’t seen them say anything on healthcare doesn’t mean they haven’t or aren’t about to. Maybe they’re all working on a buy-in but all the air’s been taken up by anticipation of this bill. Maybe not, but it wouldn’t be the first time that’s happened.

    @Jim, Foolish Literalist: can you even score a proposal with this many funding holes? It’s not a real bill.

    ReplyReply
  61. 61
    gene108 says:

    @Bailey:

    We want to maintain a bloated, expensive and often inefficient insurance system because of the people who work in the insurance industry?

    Yeah, mass lay-offs is a selling point.

    Manufacturing is very efficient, and far more productive, compared to what it was 50 years ago. People don’t seem to be too happy about it.

    ReplyReply
  62. 62
    DHD says:

    @Major Major Major Major: Canada (except Quebec*) does ban private insurance for “medically necessary services” which is, I think, the same thing as what the Bernie bill proposes. There is a well-established argument for this which is, basically, that it prevents the emergence of a parallel privately-funded system that gets to cherry-pick all the easy cases. In other words, it stops the system from devolving into what you have in the USA where the government picks up the tab for the poor, the old, the disabled, and the war-wounded, and private industry gets to profit off of everybody else.

    In practice, I think that as long as everybody is still paying for the public system, this slippery-slope argument is not valid, because the public and private systems end up competing with each other to some extent, and the value added by going private is mostly stuff like “your own room and an a la carte menu”. There is, though, always the danger that a right-wing party campaigns on a platform of “why should the Middle Class (by which they actually mean the 1%) pay for this crappy public system where you can’t find a doctor and you have to wait months to get your hip replaced” and decides to privatize the whole thing.

    *In practice you cannot buy insurance in Quebec that will cover any procedures (medically necessary or not) in private clinics, because it makes no sense for insurance companies to sell it. However, private insurance will cover blood tests and such done privately which I don’t think is the case in the Rest of Canada.

    ReplyReply
  63. 63

    @DHD: doesn’t France let you buy boutique luxury insurance like you describe though? This sort of ban is not necessary.

    ReplyReply
  64. 64
    gene108 says:

    @Jim, Foolish Literalist:

    But Wilmer has convinced a loud and electorally significant number of voters

    They didn’t need convincing. They were the ones, who threw a fit, when Obamacare was rolled out without a public option.

    Bernie just speaks their language and has them fired up and aimed at the real enemy: Democrats.

    ReplyReply
  65. 65
    Amanda in the South Bay says:

    @Barbara: the problem with comparing America to other countries with civilized health care systems is that our electorate is much further to the right, one of our two major parties is much more dedicated to the free market than is the case in any other Western country, and our constitutional order is archaic (federalism, veto points, filibuster, etc).

    ReplyReply
  66. 66
    Jim, Foolish Literalist says:

    Murphy’s bill is actually much more ambitious than Stabenow’s (buy-in at 55) or the House bill (buy-in at 50)

    Sen. Chris Murphy, a potential presidential contender, is working on legislation expected this fall that would let every individual and business buy into Medicare as part of Obamacare’s exchanges. As Sanders and other potential challengers to President Donald Trump flock to “Medicare for all,” embracing a top liberal priority before 2020, Murphy is taking a conspicuously more pragmatic approach designed to get Democrats closer to that lofty but potentially unobtainable goal.

    ReplyReply
  67. 67
    Barbara says:

    @Major Major Major Major: France, Germany, and UK all have supplemental insurance. It is inconceivable to me that we would outdo them in prohibiting private insurance. It also seems bizarre to me that Sanders supporters appear to be an odd collection of nanny state zealots and libertarian bros. They can’t all want the same thing here.

    ReplyReply
  68. 68
    Barbara says:

    @Amanda in the South Bay: We are actually not necessarily the most free market nation in the developed world. It might feel that way, but it is not actually the case. The Netherlands and Switzerland both have universal coverage based purely on private insurance. To say we are more free market than, say, Germany is really uninformed. I don’t mean that as an insult. The point is that there are democratic developed nations that are intensely free market that have worked this out, as we have for Medicare and Medicaid. Agree that our federalist structure is an impediment, maybe even a suicide pill.

    ReplyReply
  69. 69
    Captain C says:

    @schrodingers_cat:

    Then he and wife can retire in a dacha paid by Putin.

    Assuming she’s not in a Federal prison for bank fraud.

    ReplyReply
  70. 70
    Kelly says:

    @Barbara:

    The point is to move the window.

    We are at least two election cycles away from enacting any Democratic health insurance changes. How we pay for it comes after there is enthusiasm for better health insurance. Maybe it’s BS to propose things we don’t know how to pay for but BS seems to be what moves politics.

    ReplyReply
  71. 71
    Le Comte de Monte Cristo, fka Edmund Dantes says:

    One million people are employed in the vicinity of medical insurance and medical billing, from Sea to shining Sea. Many of them are employed in small medical practices and hospitals in their hometowns, and they’re anywhere from 20-80 years old. They have children and mortgages and obligations, and the True Progressives have frequently announced that they have no fucks to give about their fate.

    Likewise, there are billions of dollars in index, retirement and other mutual funds that are underpinned by the presence of about 30% healthcare related issues. Union pension funds, public employee pension funds, private employee pension funds, 401Ks, 403Bs, university foundation funds, charitable trusts are all impacted by the value of healthcare equities.

    The answer by Our Progressive Betters is “why bother to be truthful about harmful consequences to the economy in implementation – there will be puppies and unicorns and kittens when there is a slide off the cliff toward medicare for all”.

    ReplyReply
  72. 72
    Bailey says:

    @gene108:

    They didn’t need convincing. They were the ones, who threw a fit, when Obamacare was rolled out without a public option.

    Bernie just speaks their language and has them fired up and aimed at the real enemy: Democrats.

    Frankly, I’d consider anyone my “enemy” who refused to lead (or participate) in such a pivotal issue.

    People who call themselves “democrats” but then piss all over everyone else trying to problem solve and find better solutions aren’t really worthy of the name.

    ReplyReply
  73. 73
    Jack the Second says:

    @Bailey:

    I don’t understand this line of argument. We want to maintain a bloated, expensive and often inefficient insurance system because of the people who work in the insurance industry?

    I don’t really want to argue in favor of a poor status quo, but you cannot disregard the human suffering caused by revolutionary change.

    Is the goal to punish the insurance industry and everyone associated it, or to provide universal healthcare for everyone in the United States?

    There are incremental, progressive ways to regulate the daylights out of the insurance industry, as every (pseudo-)monopoly should be, to expand coverage and provide healthcare to the poor at the expense of the rich. I don’t like revolutionary change; it’s disruptive, and there’s no guarantee the eventual gains to humanity will outweigh the up-front costs of human suffering. And when revolutionary change doesn’t work out, it’s usually followed up by more revolutionary change, which is just another throw of the dice.

    ReplyReply
  74. 74
    Kelly says:

    @Barbara: I find your comments to David’s post’s the most interesting and useful.

    ReplyReply
  75. 75
    MomSense says:

    @Le Comte de Monte Cristo, fka Edmund Dantes:

    Our progressive betters only care about coal miners and factory workers. Besides a lot of those medical provider and insurance billing workers are women and not as important as the manly mining and manufacturing workers.

    ReplyReply
  76. 76
    Chet says:

    The window of opportunity is shut. This is about getting ducks in a row for when it opens.

    This. Republicans screeched for seven years about how they needed to repeal and replace Obamacare, while little by little their ability to do just that became stronger. Yet all they could offer was PowerPoint slides. When it finally happened that they got a majority in both houses and the presidency, I expected Obamacare to be gone by COB on 1/20/2017. Instead, they circled the drain and drowned, because they never had a plan in the first place.

    ReplyReply
  77. 77
    gratuitous says:

    Anything worth doing is worth doing badly. Universal health care is a f’rinstance.

    Get something in place, even if it’s not perfect. Especially if it’s not perfect. Let’s get something in place, see how it works, then fix it where it doesn’t work. Right now the national conversation is running favorably toward the concept of single payer. It’s on people’s radar, and it sounds like a good idea to them. Get something in place that will work for 75% of the people, then amend it to work better for 20% of those left out. Then work on those last 5%. It won’t work perfectly from Day One, but let’s get used to the idea that that’s all right. Social Security works better and in more ways than its architects ever imagined. But we’ve had 75 years to tinker with it. The same will work for a national health plan.

    Wealthy people will always be able to jump the line, there will always be specialty and boutique clinics that cater to the well off. Don’t pay any attention to whining from them. They will not be dying of treatable ailments except by stubborn choice. Let’s make the system work better for as many people as we can.

    ReplyReply
  78. 78
    Le Comte de Monte Cristo, fka Edmund Dantes says:

    @dr. bloor:

    Looking at the Sanders/Stein left(spit), it is apparent that the answer to the negative consequences of implementing that game of musical chairs will be this:

    “Who could have predicted that massive recession after the stock slide and huge new numbers of unemployed people? It was all supposed to work – True Progressivism is disruptive, and things will probably get better, sometime”.

    If 2020 is Trump vs Sanders, I’m expatriating. They’re both loathesome, lazy, authoritarian narcissists, out to wreck our country.

    ReplyReply
  79. 79
    Bailey says:

    @MomSense:

    Our progressive betters only care about coal miners and factory workers. Besides a lot of those medical provider and insurance billing workers are women and not as important as the manly mining and manufacturing workers.

    Is there any indication that, say, people who worked at video stores were unable to find other employment once iTunes and Netflix came around? Not really.

    Assuming that skills can’t be transferrable (or even absorbed into a different system) is a very poor way of implementing progress.

    ReplyReply
  80. 80
    Mike J says:

    So if you ever accept money outside the government run system you can’t accept any patients under it?

    If you’re a plastic surgeon who makes large dollars from doing quick and lucrative boob jobs, you can’t get paid by the government for doing post mastectomy reconstructive surgery? Can’t help burn victims unless you turn down nose jobs?

    ReplyReply
  81. 81
    Le Comte de Monte Cristo, fka Edmund Dantes says:

    @Bailey:

    You’re a fucking asshole. A hypothetical 45 year old single mom of middle school kids working as a supervisor the claims department in a small hospital in her hometown of Lancaster Ohio isn’t a statistic – her 40K a year pays for her home and transportation, and taking it will gut an entire family. There has to be a long transition, and the shocks have to be mitigated by a massive public investment. That lazy, incompetent fuck Sanders offers up some free college – which would ALSO have to be paid for and wouldn’t help – plus, you’d be looking at people starting their economic lives from scratch in their 50s.

    ReplyReply
  82. 82
    Jack the Second says:

    @Bailey: Netflix was founded 1997. Blockbuster became defunct 2014 (and there are still ~10 franchise-owned blockbusters left in the US). Blockbuster employed, at its peak, 50,000 people in the US, in 2004, and declined slowly thereafter, un-employing approximately 100 people per week between 2004 and 2014.

    I would argue there is a little bit of a difference between the slow shifts as companies and industries rise and fall and the government outlawing an industry that employs millions of people over the course of 4 years.

    ReplyReply
  83. 83

    @Bailey:

    OK, I admit I wasn’t paying attention back there – I was too busy eating pie.

    At least you’re being honest.

    ReplyReply
  84. 84
    Another Scott says:

    @Barbara: It’s all your caveats that elaborate on my reasons for saying that California is too small. ;-) There’s too big a potential barrier to hope over, or tunnel-through, for California (or any other state) to get there on its own. It has to be national, or it has to be incremental with a lot of Federal buy-in (which is kinda-sorta the same thing).

    Cheers,
    Scott.

    ReplyReply
  85. 85
    Bailey says:

    @Le Comte de Monte Cristo, fka Edmund Dantes:

    You’re a fucking asshole. A hypothetical 45 year old single mom of middle school kids working as a supervisor the claims department in a small hospital in her hometown of Lancaster Ohio isn’t a statistic – her 40K a year pays for her home and transportation, and taking it will gut an entire family. There has to be a long transition, and the shocks have to be mitigated by a massive public investment. That lazy, incompetent fuck Sanders offers up some free college – which would ALSO have to be paid for and wouldn’t help – plus, you’d be looking at people starting their economic lives from scratch in their 50s.

    So everyone else should have their economic lives sacrificed so that people who work in the insurance industry (and who knows if they’re even happy about it) should be accommodated? And you are just assuming that those who work in insurance industry now couldn’t transfer to working in the medicare for all structure? Very short-sighted.

    But if it makes you feel better to call me a fucking asshole, go for it.

    ReplyReply
  86. 86
    Bailey says:

    @Jack the Second:

    Netflix was founded 1997. Blockbuster became defunct 2014 (and there are still ~10 franchise-owned blockbusters left in the US). Blockbuster employed, at its peak, 50,000 people in the US, in 2004, and declined slowly thereafter, un-employing approximately 100 people per week between 2004 and 2014.

    I would argue there is a little bit of a difference between the slow shifts as companies and industries rise and fall and the government outlawing an industry that employs millions of people over the course of 4 years.

    How quickly do you think this transformation would take place? Over four years? Doubtful. Even ACA took 4 years for all benefits to kick in an that was using near exact structure.

    ReplyReply
  87. 87
    Le Comte de Monte Cristo, fka Edmund Dantes says:

    @Jack the Second:

    Bailey is a “disruptive internet progressive”, and as such, is fine with breaking some eggs to make his omelet of wonderfulness. If it takes a massive depression and 12% unemployment to get there, no sacrifice by others is too great.

    This is being done with the same planning aforethought as the Afghan and Iraq occupations.

    ReplyReply
  88. 88
    Jim, Foolish Literalist says:

    @Le Comte de Monte Cristo, fka Edmund Dantes: I get an insincere troll-y vibe off that one, but s/he does capture the voice of the Wlimerite with precision

    this could be Sarandon or Moore or our very own Kropadope

    Frankly, I’d consider anyone my “enemy” who refused to lead (or participate) in such a pivotal issue.

    People who call themselves “democrats” but then piss all over everyone else trying to problem solve and find better solutions aren’t really worthy of the name.

    ReplyReply
  89. 89
    Jack the Second says:

    @Bailey:

    So everyone else should have their economic lives sacrificed so that people who work in the insurance industry (and who knows if they’re even happy about it) should be accommodated? And you are just assuming that those who work in insurance industry now couldn’t transfer to working in the medicare for all structure? Very short-sighted.

    But if it makes you feel better to call me a fucking asshole, go for it

    And there are non-revolutionary ways to tweak the existing system to achieve a goal of truly universal coverage. Is the goal to punish the insurance industry and everyone associated it, or to provide universal healthcare for everyone in the United States?

    ReplyReply
  90. 90
    Jack the Second says:

    @Bailey:

    How quickly do you think this transformation would take place? Over four years? Doubtful.

    From the post we’re commenting on explaining the proposal under discussion:

    The bill would be in full effect on the 4th January 1st after the bill is signed into law.

    Private insurance contracts that cover the same services as the Universal Medicare system would be banned. Service contracts would be allowed but as soon as a medical service provider receives a single dollar from one of these contracts, they lose eligibility to receive any payments from the Universal Medicare system for a year.

    ReplyReply
  91. 91
    Bailey says:

    @Jack the Second:

    And there are non-revolutionary ways to tweak the existing system to achieve a goal of truly universal coverage. Is the goal to punish the insurance industry and everyone associated it, or to provide universal healthcare for everyone in the United States?

    I’d say it is the latter, but I don’t believe whatever universal coverage we can get in place using our patchwork system will ever be as efficient as other countries because of the bloat of our current insurance market and their practices. Even with ACA, they don’t have competition at all and the cost bending has not been dramatic enough for people to see or appreciate. At best, we are keeping costs from rising as high as they could, not actually saving people money. I also don’t see “Medicare for All” as violently revolutionary considering we already have Medicare.

    ReplyReply
  92. 92
    chopper says:

    @gratuitous:

    Get something in place, even if it’s not perfect. Especially if it’s not perfect. Let’s get something in place, see how it works, then fix it where it doesn’t work.

    i don’t think this is wise with a system that makes up almost a fifth of our country’s economy and upon which millions of people’s lives depend. nor do i think there will be as much political will towards fixing it if it doesn’t work very well in the beginning; people will sour on the whole concept instead.

    ReplyReply
  93. 93
    chopper says:

    @Jack the Second:

    exactly. video store workers and elevator operators are a pretty dumb example here.

    ReplyReply
  94. 94
    Jim, Foolish Literalist says:

    @chopper: to be fair, that is, or is supposed to be, the process we’re going through with O’care

    ReplyReply
  95. 95
    chopper says:

    @Jim, Foolish Literalist:

    i don’t think obamacare was an example of ‘let’s just do something and see what happens’. obamacare was ‘this may only be the first step, but it will help a great deal’. it wasn’t written by the healthcare version of the underpants gnomes.

    ReplyReply
  96. 96
    Elie says:

    @gene108:

    “Private insurance has two negatives. One is billing issues. The other is they say no to things, like not allowing a more aggressive treatment versus something more routine, when you know only the more aggressive treatment will help your condition”

    Hate to break it to you but it is unlikely that all billing would go away, but most importantly, the government, just like the insurance companies, will absolutely have to say NO to things. We just saw an example of that recently in the UK with the baby with a hopeless genetic anomaly whose parents wanted treatment anyway. NO is unfortunately necessary.

    In regards to Bernie’s announcement, I truly hate that he seems to be hinting that all of this improvement is without any cost — either financial or in terms of how and who delivers your health care services. Sigh. Again, it sets up expectations that cannot be delivered and Democrats better be vewy vewy careful —

    I wish this was someone else’s initiative. I just don’t trust this guy or any of his motivations which I do not believe are above suspicion.

    ReplyReply
  97. 97
    Elie says:

    @Bailey:

    1. It is hard to achieve cost savings when you are under constant political and as a consequence, financial attack. Cost control requires uniform commitment and knowledge as well as acceptance of certain outcomes and goals. ACA could not, thanks to the red states governors, get the coverage or stability intent to begin to move the costs.

    2. Medicare for All is a slogan hiding a whole hell of a lot more than people like you think. Did you know, for example, that there is out of pocket costs of coverage, that supplemental insurance may be necessary, that not all Medicare covers the same things — For example Medicare Advantage is a plan styled coverage that has a different benefit package than FFS Medicare. And what about medications

    ReplyReply
  98. 98
    Jim, Foolish Literalist says:

    @Elie: I wish this was someone else’s initiative. I just don’t trust this guy or any of his motivations which I do not believe are above suspicion.

    History suggests that Himself is in fact willing to compromise and vote for half a loaf when push comes to shove, at least until January 2016– which in my recollection is when he convinced himself he could actually win the nomination and the presidency. And his toxic, weaponized sanctimony, his dangerously reductive and self-righteous oversimplification of the political process, has morphed into a cult of personality. At least judging by twitter (yeah, yeah, but Jill Stein voters delivered* the electoral college to trump), his supporters don’t know or care about the details, they know BERNIE! and BERNIE! say this can be, this should be, this must be. Those who are not Of The Body must be destroyed.

    ReplyReply
  99. 99
    Bailey says:

    @Elie:

    1. It is hard to achieve cost savings when you are under constant political and as a consequence, financial attack. Cost control requires uniform commitment and knowledge as well as acceptance of certain outcomes and goals. ACA could not, thanks to the red states governors, get the coverage or stability intent to begin to move the costs.

    Okay, so perhaps Medicare for All can. I’m not disparaging ACA because it was a huge leap forward and Obama was masterful in getting what he could through. But it was easier for red state governors to say “no” on this because it was a “new” program and easy to create doubt about. Everyone knows what Medicare is already.

    2. Medicare for All is a slogan hiding a whole hell of a lot more than people like you think. Did you know, for example, that there is out of pocket costs of coverage, that supplemental insurance may be necessary, that not all Medicare covers the same things — For example Medicare Advantage is a plan styled coverage that has a different benefit package than FFS Medicare. And what about medications

    Yes, I did know all this. I don’t see how that adds or detracts from the discussion however.

    ReplyReply
  100. 100
    msdc says:

    @tobie: Yeah, it’s almost like the last time they made a big push on health care reform the voters punished them for it, while the left called them sellouts!

    I wonder why they haven’t been eager to run back into that buzzsaw.

    ReplyReply
  101. 101
    TenguPhule says:

    @Cheryl Rofer:

    Plus hearing about it will give people hope and start them thinking about what a great world it could be.

    Funny, we thought that when the ACA was proposed.

    Look what our ignorant Republican Fluffing media managed to do to it.

    ReplyReply
  102. 102
    Barbara says:

    @Another Scott: It’s not “smallness” that is California’s problem. California has more people than Canada. Smallness isn’t the problem. Being structurally part of a federal system in which the majority of dollars are not actually or even potentially controlled by California is the problem. It’s a different problem and identifying the problem is meaningful to solving it. Calling California “too small” sounds silly because it is silly. I don’t want to hurl insults, it’s not my style, but by using the “too small” label you are diverting attention from the real issues.

    ReplyReply
  103. 103
    TenguPhule says:

    @Bailey:

    We want to maintain a bloated, expensive and often inefficient insurance system because of the people who work in the insurance industry?

    Wall Street,

    Too Big to Fail.

    ReplyReply
  104. 104
    TenguPhule says:

    @msdc:

    I wonder why they haven’t been eager to run back into that buzzsaw.

    A true progressive fears neither pain, nor death nor irrelevance.

    ReplyReply
  105. 105
    TenguPhule says:

    @Bailey:

    Okay, so perhaps Medicare for All can. I’m not disparaging ACA because it was a huge leap forward and Obama was masterful in getting what he could through. But it was easier for red state governors to say “no” on this because it was a “new” program and easy to create doubt about. Everyone knows what Medicare is already.

    Uh, you do realize many Republican controlled states turned down Medicaid expansion.

    ReplyReply
  106. 106
    Bailey says:

    @TenguPhule:

    Wall Street,

    Too Big to Fail.

    Not really the same thing. Wall Street was “too big to fail” because virtually everyone in the middle class had their retirement and personal wealth somehow tied to Wall Street. This is not true for the health care industry.

    ReplyReply
  107. 107
    Bailey says:

    @TenguPhule:

    Uh, you do realize many Republican controlled states turned down Medicaid expansion.

    Yes, because Medicaid is for poor people and “others.” Medicare is not perceived the same way.

    Regardless, states aren’t really being given that same choice in setting up their exchanges in this scenario, so a moot point.

    ReplyReply
  108. 108
    Citizen Alan says:

    @Ohio Mom

    Well, ya see, Bernie would have beaten Trump quite easily in the general had all those uppity b****** not conspired to steal the primary way from him, doncha know.

    ReplyReply
  109. 109
    TenguPhule says:

    @Bailey:

    Wall Street was “too big to fail” because virtually everyone in the middle class had their retirement and personal wealth somehow tied to Wall Street. This is not true for the health care industry.

    The insurance industry and the health care industry are both major employers, major investments for financial instruments and carry a lot of clout on the lobbying and voting levels.

    If you think trying to seriously gut one and disrupt the other isn’t going to result in severe blowback from many parties, you need to go back and look at the fight over the ACA.

    ReplyReply
  110. 110
    TenguPhule says:

    @Bailey:

    Regardless, states aren’t really being given that same choice in setting up their exchanges in this scenario, so a moot point.

    Which results in multiple lawsuits by those same states.

    With a Republican controlled court system.

    ReplyReply
  111. 111
    Bailey says:

    @TenguPhule:

    The insurance industry and the health care industry are both major employers, major investments for financial instruments and carry a lot of clout on the lobbying and voting levels.

    If you think trying to seriously gut one and disrupt the other isn’t going to result in severe blowback from many parties, you need to go back and look at the fight over the ACA.

    Yeah, no shit the insurance companies aren’t going to put up a fight. That’s a given. So what? The point is that most individuals in this country do not have their personal wealth tied up in insurance companies–regardless of them being options for investment vehicles–the same way that pensions were tied to Wall Street in general.

    ReplyReply
  112. 112
    Bailey says:

    @TenguPhule:

    Which results in multiple lawsuits by those same states.

    With a Republican controlled court system.

    Your vote has been duly noted. Sit back and do nothing. Status quo works. Got it.

    ReplyReply
  113. 113
    TenguPhule says:

    @Bailey:

    Your vote has been duly noted. Sit back and do nothing. Status quo works. Got it.

    Why is it always binary choices with you people? There are a lot of other options between do nothing and wishing for unicorns.

    ReplyReply
  114. 114
    Bailey says:

    @TenguPhule:

    Why is it always binary choices with you people? There are a lot of other options between do nothing and wishing for unicorns.

    There sure is. In fact, you can spend your time labeling everything a unicorn, for example.

    ReplyReply
  115. 115
    TenguPhule says:

    @Bailey:

    Yeah, no shit the insurance companies aren’t going to put up a fight. That’s a given. So what? The point is that most individuals in this country do not have their personal wealth tied up in insurance companies–regardless of them being options for investment vehicles–the same way that pensions were tied to Wall Street in general.

    The point is that unlike Wall Street, which everyone generally hates, Healthcare and Insurance and all of the associated people economically tied to them touch a lot of people across the country. Its like trying to pick a fight with the AARP by saying you want to ban all the current members. Even people not in the AARP will turn on you because they have people they know and love in the AARP.

    If you want to improve healthcare and coverage you can’t just say you want to blow everything up for them and tough titties if they suffer. You’ll face a united front determined to stop you and that will hold grudges forever, which Democrats DO NOT NEED.

    Frankly, we’ve got more urgent priorities to deal with, single payer shouldn’t even be making the top 10 in the things to actually be concerned about fixing right now.

    ReplyReply
  116. 116
    VeniceRiley says:

    @narya:

    And I wonder what happens to community health centers (FQHCs). It sounds like the 340b money would go away, which would dramatically alter the finances of FQHCs, especially the ones who serve people with HIV, hep c, some MH issues, etc. More than 26,000.000 people received care from an FQHC last year, so it’s a non-trivial question/population.

    It’s an interesting question, as well as the other – non-perm residents and non-citizens and other uninsured- the burden will still be on the FQHC I am sure and they should continue to receive additional funding because they keep all those people healthy and out of the ER.
    If I worked in the Gov’t Relations department, I could tell you what happens to 340b. ( Is that that rX pricing thing?) But I work in IT.
    The FQHC I work for has pharmacies in the facility and contracted pharmacists. (I use them myself. It’s great having them onsite.)

    Kudos to Mr. Anderson for making my eyes glaze over all the time- and yet I still read his every post.

    ReplyReply
  117. 117
    Bailey says:

    @TenguPhule:

    The point is that unlike Wall Street, which everyone generally hates, Healthcare and Insurance and all of the associated people economically tied to them touch a lot of people across the country. Its like trying to pick a fight with the AARP by saying you want to ban all the current members. Even people not in the AARP will turn on you because they have people they know and love in the AARP.

    Yeah, I forgot how much Americans absolutely love their insurance company. I doubt there’s anyone in the country who doesn’t think there’s room for improvement.

    If you want to improve healthcare and coverage you can’t just say you want to blow everything up for them and tough titties if they suffer. You’ll face a united front determined to stop you and that will hold grudges forever, which Democrats DO NOT NEED.

    How is it “blowing something up” to take an existing program and expand it?

    Frankly, we’ve got more urgent priorities to deal with, single payer shouldn’t even be making the top 10 in the things to actually be concerned about fixing right now.

    Really? 10 more priorities than health care? Okay, if you say so.

    ReplyReply
  118. 118
    Barbara says:

    @VeniceRiley: I can tell you what happens to 340B. With any kind of attention, it would be supplanted by a saner and less fragmented way of lowering the cost of drugs.

    ReplyReply
  119. 119
    NR says:

    @msdc:

    Yeah, it’s almost like the last time they made a big push on health care reform the voters punished them for it, while the left called them sellouts!

    The voters punished them because the bill they passed was more concerned with protecting the profits of the big insurance companies than it was with improving the nation’s health care system.

    So, you know, if they don’t do that again, they won’t have the same problems.

    ReplyReply
  120. 120
    NR says:

    @Elie:

    In regards to Bernie’s announcement, I truly hate that he seems to be hinting that all of this improvement is without any cost

    Single-payer saves money. You only have to look at Europe, where every country with single-payer spends less money for better health care than we do.

    I wish this was someone else’s initiative. I just don’t trust this guy or any of his motivations which I do not believe are above suspicion.

    And you people say that Bernie supporters are the ones who can’t get over the primary.

    Single-payer is needed reform. The cost of the current system is unsustainable. Which is why more and more Democrats like Kamala Harris and Tammy Baldwin are getting on board with it.

    ReplyReply
  121. 121
    Another Scott says:

    @Barbara: Sorry.

    Maybe “small” isn’t the right word. I think we agree that the issue is that a state in the USA – even one as big as California – can’t go it alone (unless there are substantial changes to the national system, which in effect creates a national system) because of the way the heath care system in the USA works. That’s all I was trying to say.

    Cheers,
    Scott.

    ReplyReply
  122. 122
    NR says:

    @Le Comte de Monte Cristo, fka Edmund Dantes:

    A hypothetical 45 year old single mom of middle school kids working as a supervisor the claims department in a small hospital in her hometown of Lancaster Ohio isn’t a statistic – her 40K a year pays for her home and transportation, and taking it will gut an entire family.

    Just curious, do you use the same argument to say that we should keep locking people up at a rate greater than anywhere else in the world? Prison guards have jobs and homes and families too, you know. Or do you only trot out that argument when it’s time for you to indulge in your favorite pastime of hippie-punching?

    ReplyReply
  123. 123
    Jim, Foolish Literalist says:

    “You’ll pay more in taxes, but per capita we’ll spend less on health care. Just look at Europe!”

    there’s a message that can’t fail!

    ReplyReply
  124. 124
    TenguPhule says:

    @NR:

    The voters punished them because the bill they passed was more concerned with protecting the profits of the big insurance companies than it was with improving the nation’s health care system.

    I’m sure the insurance companies were just demanding that pre-existing conditions be allowed and lifetime caps removed.

    And surely everyone was objecting to having child coverage extended to 26.

    Oh wait.

    ReplyReply
  125. 125
    AnonPhenom says:

    Several excellent rationals in this thread for never doing something about anything because of the likelihood somebody somewhere could be affected negatively. Possibly for months!
    Sounds like winning to me!
    Go Dems!

    ReplyReply
  126. 126
    NR says:

    @Jack the Second:

    There are incremental, progressive ways to regulate the daylights out of the insurance industry, as every (pseudo-)monopoly should be, to expand coverage and provide healthcare to the poor at the expense of the rich. I don’t like revolutionary change; it’s disruptive, and there’s no guarantee the eventual gains to humanity will outweigh the up-front costs of human suffering.

    Your argument ignores two key facts:

    1. Obamacare, the poster child for incremental reform, was a political disaster. We lost the House and the Senate, and suffered nearly unprecedented losses at the state level around the country. Obamacare was enacted based on arguments of political expediency.  It failed in its own terms.

    2. The current system is in crisis.  It is not sustainable.  Medicare in 2030 will be hemorrhaging money, and modest incremental reforms won’t stop it.

    You either pursue revolutionary change, or over time the people that want to gut Medicare and Medicaid are going to win. There is no middle ground here.

    ReplyReply
  127. 127
    Jim, Foolish Literalist says:

    @NR: The voters punished them because the bill they passed was more concerned with protecting the profits of the big insurance companies than it was with improving the nation’s health care system.

    Yup. That’s how the Dem-Soc’lists won all those House races in Kentucky, Arkansas, West Virginia, Michigan, Ohio….

    You are very smart.

    ReplyReply
  128. 128
    Jim, Foolish Literalist says:

    @AnonPhenom: Several excellent rationals in this thread for never doing something about anything

    Yes. Because there are only two alternatives here. Bernie’s maximalist half-baked sloganeering, and “never doing something about anything”.

    You’re so smart, I wonder if NR has created a sock-puppet of smart.

    ReplyReply
  129. 129
    Recall says:

    @Jim, Foolish Literalist:
    @Jim, Foolish Literalist:

    You two should really get your own usernames.

    ReplyReply
  130. 130
    NR says:

    @TenguPhule: The insurance companies wanted a mandate where everyone in America was forced to buy their product. They got what they wanted.

    Meanwhile, 70% of the country wanted a public option so the insurance companies would have some competition, and the Democrats killed it because it would have hurt insurance company profits.

    Gee, I can’t imagine why voters might not br happy about that.

    ReplyReply
  131. 131
    AnonPhenom says:

    As me sainted mother used to say

    You can always find a reason NOT to do something

    ReplyReply
  132. 132
    TenguPhule says:

    @NR:

    Meanwhile, 70% of the country wanted a public option so the insurance companies would have some competition, and the Democrats killed it because it would have hurt insurance company profits.

    Oh FFS, we didn’t have the votes for the public option. We barely had the votes for the ACA. That’s what happens when you have a razor thin majority and voters elect assholes.

    And the Democrats as a whole got demonized as “death panels” and “they raised my insurance rates” by a thick as mud media for their troubles.

    ReplyReply
  133. 133
    NR says:

    @Jim, Foolish Literalist:

    That’s how the Dem-Soc’lists won all those House races in Kentucky, Arkansas, West Virginia, Michigan, Ohio….

    Gee, you mean the candidates running under the banner of the party that just put corporate profits over doing what was best for the country?

    Can’t imagine why that didn’t fly.

    ReplyReply
  134. 134
    TenguPhule says:

    @NR:

    The current system is in crisis. It is not sustainable.

    Guess what, the Democrats can’t do anything about this now.

    And Trump is creating so many ticking time bombs that you are going to have to take a number and wait your turn while the more urgent fires are being put out.

    ReplyReply
  135. 135
    Elie says:

    @Bailey:

    The discussion, as you say, is absolutely necessary. I am just careful about comments and tone that seem to wave aside the complexities.

    I hope that the Democrats sweep the House and grab the Senate but even with that, it “Medicare for all” – or public option as I would prefer, will be a heavy lift. You ready yourself for that and for that hit that will follow. Post ACA we lost majorities in both houses and down the food chain. Very few Democrats actually stood up for all the effort and sacrifice that they made to pass ACA but indeed, ran away from it.

    Also, the last thing that we need is members of the Bernie “Purity Police” going after Dem candidates in red states – or elsewhere, who bring up any cautionary points or advocate for slightly different approach. I will be furious if we are held hostage to these people to prevent tearing our party to pieces so that they can get their ponies. I hold Bernie responsible for all that follows….. As I have said, I am very suspicious of his motives….

    ReplyReply
  136. 136
    NR says:

    @TenguPhule:

    Oh FFS, we didn’t have the votes for the public option.

    Oh look, it’s “we didn’t have the votes.” Time to party like it’s 2009!

    Saying “we didn’t have the votes” is just another way of saying “Democrats wouldn’t vote for it.” But in any case, it’s just an excuse, and voters don’t want excuses. If that’s all you have to give them come election time, it shouldn’t be any surprise when you get your ass kicked.

    ReplyReply
  137. 137
    Jack the Second says:

    @NR:

    Medicare in 2030 will be hemorrhaging money, and modest incremental reforms won’t stop it.

    Is your ultimate argument “Medicare will be hemorrhaging money in 2030, so we need to switch exclusively to it immediately”?

    ReplyReply
  138. 138
    NR says:

    @Jack the Second: Thereby fixing it in the process. It’s really not a difficult concept.

    ReplyReply
  139. 139
    Jim, Foolish Literalist says:

    @NR: NR and Bernie Dumbledore agree! Those doughty Heartlanders are all about economic anxiety. And Obamaphones. And them illegals. And keepin’ queers away from yer sons in the ladies’ room. And what’s wrong with my confederate flag? ….

    Our NR, his finger on the pulse of real America. What would we do without him?

    ReplyReply
  140. 140
    TenguPhule says:

    @NR:

    Saying “we didn’t have the votes” is just another way of saying “Democrats wouldn’t vote for it.”

    Specific democrats who had state interests in healthcare and insurance and one independent asshole would not vote for it. And due to the razor thin majority you insist on ignoring, each one of them had enormous influence on what could and could not pass. But instead of electing better Democrats, the idiots threw them out for GOP scum who promised them the world on a platter at no cost.

    ReplyReply
  141. 141

    @NR: Or the voters were punishing Democrats for being in power during a once in several lifetimes recession and the reason did not really matter beyond the fact that the economy was shittastic

    ReplyReply
  142. 142

    “I don’t understand where the money is coming from.”

    Sanders has promised to release several proposals on funding in the coming weeks. This actually makes a lot of sense: he’s personally taking the heat on the taxes, while the Democrats get to campaign on universal care.

    “I don’t agree with the level of trust in the Secretary of Health and Human Services that the bill uses … I see de facto nationalization of most medical facilities given the payment structure and contract limitations.”

    Sanders, it seems, has something of the old-time state socialist view of these matters – just nationalize the system. In the American system, though, checks and balances are important. Perhaps some of these functions ought to be reserved to the states? That would be awful in the red states. And yet, and yet, federalism and separation of powers are things protecting us against Trump and the Republicans.

    BTW, process note: has any previous national legislation been introduced in this way? This is something new, made possible by the internet. I am glad that Sanders has chosen to use these possibilities for a positive thing. And yet (you know I always have quibbles) what happens when an anti-immigrant bill is similarly introduced. I fear the possibilities for demagoguery? I fear what will happen when the fascists start using these methods.

    Where is James Madison when we need him?

    ReplyReply
  143. 143
    Barbara says:

    @Another Scott: We have two options: Create a truly national system, or enable states to create their own systems. The second is vastly more complex and I, for one, would oppose any such system that relies on what we refer to as “block grants.”

    ReplyReply
  144. 144
    Recall says:

    @TenguPhule: 59-41 in the Senate, 255-179 in the House. You need new razors.

    ReplyReply
  145. 145
    Le Comte de Monte Cristo, fka Edmund Dantes says:

    @NR:

    Just curious, do you use the same argument to say that we should keep locking people up at a rate greater than anywhere else in the world? Prison guards have jobs and homes and families too, you know. Or do you only trot out that argument when it’s time for you to indulge in your favorite pastime of hippie-punching?

    Dipshits like you do everything wrong – when you destroy occupations and economic lives by deliberate government action while failing to plan for (or even give a fuck) about mitigating the very real consequences, it creates pushback in ways that guarantee political failure on the part of the proponent.

    ReplyReply
  146. 146
    Tom65 says:

    Let me get this straight.

    We’ve been clamoring for Single Payer, or some form of it, for years. The PPACA wasn’t perfect, but there was hope that it would eventually lead to something along the lines of SP. Now that someone has introduced a bill and gotten fifteen other Senators to sign on as co-sponsors, we’re going to pick it apart? Holy fuck.

    No, it’s not a perfect bill, but it gets the ball rolling, which is one hell of lot further than it’s ever gotten before. What was the line we used to throw around here – “don’t let the perfect be the enemy of the good”? Let me guess: the Great White Satan introduced it, so therefore it must be killed.

    ReplyReply
  147. 147
    Jim, Foolish Literalist says:

    @Tom65: We’ve been clamoring for Single Payer, or some form of it, for years.

    Have we? “some form of it”? I think of Single Payer as being a pretty clearly defined thing, I didn’t know it had forms. I and most Dems I know I have been calling for Universal Health Care, or Universal Coverage, which can take many forms. SP and UC are not the same thing, and using the terms interchangeably, as some do, some out of confusion and some out of opportunism, is counterproductive. IMHO.

    ReplyReply
  148. 148
    TenguPhule says:

    @Tom65:

    but it gets the ball rolling

    No, it doesn’t.

    Democrats are a minority in Congress.

    All this does is offer an opportunity for Republicans and our lazy media to demonize improving access to healthcare.

    ReplyReply
  149. 149
    TenguPhule says:

    @Recall:

    59-41 in the Senate

    Default Republican Filibuster in place requiring 60 votes.

    But you should know this already.

    ReplyReply
  150. 150
    Barbara says:

    @TenguPhule:

    Saying “we didn’t have the votes” is just another way of saying “Democrats wouldn’t vote for it.”

    This is NR’s go to phrase. It’s what he/she says EVERY time this issue comes up. Truly, just a bunch of recycled whining.

    ReplyReply
  151. 151
    TenguPhule says:

    @Barbara:

    This is NR’s go to phrase. It’s what he/she says EVERY time this issue comes up. Truly, just a bunch of recycled whining.

    Its worse then whining. Its lying in support of the Republicans.

    When I am almighty tyrant, that will be a stoning offense.

    ReplyReply
  152. 152

    @Tom65: No, a critical eye to figure out how something actually works is needed. Right now a slogan is about what Single Payer legislation stands at. This is an attempt to see what the dream/aspirational goal looks like. And going through the bill and saying “how does X play with Y” or “What about Z and these interest groups reacting to it….” is how consensus is built so if and when there is a chance to implement, there is already a broad consensus as to what trade-offs are acceptable and what trade-offs are not and people who need to actually make the damn thing work have a reasonable confidence that the damn thing will work.

    Going with a slogan is what produced Iraq, going with a slogan is what killed Republicans on healthcare in 2017.

    ReplyReply
  153. 153
    Jack the Second says:

    @Tom65: This proposal doesn’t build on the PPACA, it more-or-less throws it away and starts over.

    Building on the PPACA to gradually work towards single-payer would be things like introducing a public option, making Medicare actually “single payer” (and lowering the eligibility age), or expanding Medicaid to eat more of the low income/individual insurance market.

    ReplyReply
  154. 154

    @David Anderson: And the Dems blew the response to the crash of 2008, big time: not enough on jobs, not enough on mortgage fraud.

    ReplyReply
  155. 155
    Fr33d0m says:

    I’m not sure I understand how anyone wouldn’t think that single payer would essentially get rid of the insurance market, or at least impact it heavily.

    This is an initial wag and some of these things will need to change, but right now this seems more a mechanism to allow candidates to preen themselves. As an opening salvo I would expect lots of points that need refined and explained.

    ReplyReply
  156. 156
    NR says:

    @Le Comte de Monte Cristo, fka Edmund Dantes: Nice rant, but it didn’t answer the question at all. Which itself was an answer, of course. It is just all about hippie-punching for you, and those crocodile tears you’re shedding over those poor, poor insurance company workers are nothing more than a means to that end. You’re quite transparent, you know.

    ReplyReply
  157. 157
    NR says:

    @TenguPhule:

    Default Republican Filibuster in place requiring 60 votes.

    Which the Democrats could have done away with at any time with a simple majority vote.

    But you should know this already.

    ReplyReply
  158. 158
    NR says:

    @TenguPhule: It’s not lying, it’s the plain, simple truth. The Democrats had majorities in both houses of Congress. The only way to not have the votes for something is if Democrats wouldn’t vote for it.

    It’s not a difficult concept, but it’s too difficult for you, apparently.

    ReplyReply
  159. 159
    TenguPhule says:

    @NR:

    The Democrats had majorities in both houses of Congress. The only way to not have the votes for something is if Democrats wouldn’t vote for it.

    What part of 1 or 2 defections would prevent a bill from passing in the Senate when the Democrats had their slim majority is too hard for you to understand?

    ReplyReply
  160. 160
    Bailey says:

    @Tom65:

    Let me get this straight.

    We’ve been clamoring for Single Payer, or some form of it, for years. The PPACA wasn’t perfect, but there was hope that it would eventually lead to something along the lines of SP. Now that someone has introduced a bill and gotten fifteen other Senators to sign on as co-sponsors, we’re going to pick it apart? Holy fuck.

    No, it’s not a perfect bill, but it gets the ball rolling, which is one hell of lot further than it’s ever gotten before. What was the line we used to throw around here – “don’t let the perfect be the enemy of the good”? Let me guess: the Great White Satan introduced it, so therefore it must be killed.

    As it turns out, Democrats (though thankfully not dozen highlighted in the Senate today) have learned absolutely nothing about moving the Overton window to the left.

    I agree with David (OP) that these proposals would need to be examined, tested, improved, etc, which is a bit more honest than just “picked apart.” But the other arguments in this thread, i.e. that we must keep our existing structure in place so that medical billing people can keep that job forever and ever are transparently stupid and non-productive.

    ReplyReply
  161. 161
    NR says:

    @TenguPhule: What part of “60-40 is not a ‘slim’ majority” don’t you understand?

    ReplyReply
  162. 162
    Tom65 says:

    Look, we all know that this specific bill won’t pass. It’s value is in opening a serious dialog.

    ReplyReply
  163. 163
    Elie says:

    @Jack the Second:

    And the throwing away of PPCA — and what has been accomplished to build from — to me would be an extraordinary mistake. Even a puppy doesn’t poop where it eats and I am not sure the advocates for this are thinking real world at all…

    ReplyReply
  164. 164
    Bailey says:

    @Elie:

    And the throwing away of PPCA — and what has been accomplished to build from — to me would be an extraordinary mistake. Even a puppy doesn’t poop where it eats and I am not sure the advocates for this are thinking real world at all…

    I don’t think this is throwing anything away at all. But right now Obamacare is in a precarious position and a long way away from being fully effective. The odds that any of the states that haven’t yet expanded Medicaid will do so now are slim. (Exception might be Kansas whose legislature did vote for the expansion but Gov. Brownback vetoed it. Brownback is on his way out.)

    If Dems keep forcing single payer as the alternative, this may force the GOP to defend Obamacare, as they will soon see it as the next best option.

    ReplyReply
  165. 165
    TenguPhule says:

    @NR:

    What part of “60-40 is not a ‘slim’ majority” don’t you understand?

    What part of 60 votes to override the automatic fililbuster imposed by Republicans at the time is so hard for you to comprehend? Are the words too big or just the numbers involved?

    ReplyReply
  166. 166
    TenguPhule says:

    @Bailey:

    I don’t think this is throwing anything away at all.

    Should have stopped at the first three to be completely honest.

    ReplyReply
  167. 167
    Unknown known says:

    @Another Scott:

    As huge as California is, even they are too small to have a universal healthcare system

    You realize that California is roughly twice the size of Canada

    ReplyReply
  168. 168
    Bailey says:

    @TenguPhule:

    Should have stopped at the first three to be completely honest.

    Thank you for demonstrating, once again, how very little you have to add to any discussion. Your insults are like clockwork.

    ReplyReply
  169. 169
    pseudonymous in nc says:

    It’s Overton Window stuff: it’s using an already existing US model (Medicare) and properly engaging with how the rest of the developed world does universal healthcare.

    I’d take something like the ACA evolved into a Swiss-style system. It isn’t “Medicare-for-all” but Sanders is taking the right approach by attacking the form-filling “consumer choice” shit.

    ReplyReply
  170. 170
    NR says:

    @TenguPhule: What part of the Democrats could have done away with the filibuster at any time with a simple majority vote don’t you understand? Do you not understand all of the words in that sentence, or just some of them?

    ReplyReply
  171. 171
    NR says:

    @Bailey: Like most Democratic establishment apologists, TenguPhule is quick to resort to insults when the hollowness of his arguments is exposed.

    ReplyReply
  172. 172
    Bob Hertz says:

    Let’s take a first look at the financing of single payer:

    330 million citizens
    minus 60 million on Medicare (which will never be folded into single payer)
    minus 20 million in the military, in prisons, Indian reservations, et al

    leaving 250 million persons to cover

    Current Medicaid costs for the expanded population under ACA are running close to $5,000 a person.

    This means we need about $1.25 trillion to cover the nation. (this does not include coverage for long term care)

    Where can the Democrats get a new $1.25 trillion?

    A new payroll tax of 15% on absolutely all firms would raise close to $1 trillion. A 4% income tax surcharge on all income over about $150K a year might raise the rest.

    I do not see how a 15% payroll tax would ever pass. Suppose you own 4 McDonald’s restaurants today, and you keep everyone at less than 30 hours so that you only provide health insurance to a few managers. But your actual payroll might be $2 million a year. A 15% tax means a fresh annual expense of $300,000.

    This is the kind of calculation that occurred when Vermont tried to fund single payer. This forced Vermont to move to a 10% income tax increase, including taxing seniors which will never pass either.

    Some advocates of single payer bring up the administrative savings. There would be major savings if hospitals went on global budgets and no claims were needed, no deductibles to be collected, etc. But no one in the federal bureaucracy is strong enough to impose such budgets on the Mayo Clinic, the Cleveland clinic, the for profit chains, et al.

    ReplyReply
  173. 173
    Amanda in the South Bay says:

    @Amanda in the South Bay: Thomas Piketty would disagree with you, but I’m an uninformed rando.

    ReplyReply

Leave a Comment

Leave a Reply

Your email address will not be published. Required fields are marked *