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Politics : A US National Health Care System? -- Ignore unavailable to you. Want to Upgrade?

To: Lane3 who wrote (41516)	3/21/2017 1:43:04 PM
From: Lane3	Read Replies (1) \| Respond to of 42652

The health care debate we’re not having, but should be What if conservatives said what they really believed about health care? Updated by Ezra Klein @ezraklein Mar 20, 2017, 6:10pm EDT In a mostly good column on Singapore’s health care system (I say “mostly” because it ignores the role state-regulated prices play in keeping Singapore’s costs down), Ross Douthat offers as clear a two-paragraph summary of conservative health policy thinking as I’ve seen. It’s worth quoting in full: In theory there is a coherent vision underlying Republican health care policy debates. Health insurance should be, like other forms of insurance, something that protects you against serious illnesses and pays unexpected bills but doesn’t cover more everyday expenses. People need catastrophic coverage, but otherwise they should spend their own money whenever possible, because that’s the best way to bring normal market pressures to bear on health care services, driving down costs without strangling medical innovation. This theory — along with, yes, a green-eyeshade attitude toward government expenditures on the working poor — explains why conservatives think a modest subsidy to help people buy health insurance makes more sense than Obamacare’s larger subsidies. Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be — and the more they proliferate, the cheaper health care will ultimately be for everyone. This is, obviously, a health care debate we’re not having, and it’s worth being clear about why. Reason No. 1: The coherent conservative position on health care is extremely unpopular. The most telling line in Douthat’s column is this one: “Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be.” Consider how remarkable that sentence is. Douthat is saying, sympathetically, that Republicans routinely promise a policy outcome 180 degrees from the one they’re pursuing. As much as politicians are lambasted as spin artists, this level of misdirection is rare, and for good reason — if you build public support for the opposite of the changes you want to make, those changes are unlikely to endure. There’s a reason Republicans offer such self-destructive promises. Sparer plans with higher deductibles and higher co-pays are extremely unpopular. They’re the most unpopular part of Obamacare, which is why so many Republicans — including Mitch McConnell and Donald Trump — have used high deductibles as a cudgel with which to attack the law. Republicans have used this unpopularity to their advantage, instead of trying to sell Americans on the advantages of high deductibles and laying the groundwork for the day when they might move the health care system in a more conservative direction. They are paying for that decision now, and they will suffer dearly for it if their plan actually passes. Reason No. 2: Conservatives don’t agree on or prioritize health policy. Lanhee Chen, Mitt Romney’s former policy director, has argued that Republicans fall into three camps on health care. There are those who want to expand coverage, those who think coverage is a liberal construct and the correct focus should be on cutting costs, and those who don’t think the government should be involved in health care at all. I’d add another dimension to his taxonomy: There are many conservatives — including some in all three camps — who really wish we were talking about tax reform instead. The divisions in both ideology and interest on the Republican side help explain the debate we’re not having. The unresolved ideological tensions push Republicans away from emphasizing health care issues — why focus on issues that split your coalition? Then, the reality that health care is rarely the top issue for conservatives means there are few who want to do the difficult work of persuading the country that less insurance is actually better. It’s worth thinking about tax cuts for wealthy Americans as a counterexample here. It, too, is an unpopular policy. But Republicans really agree on it, and they really care about it, and so an extraordinary amount of work goes into coming up with sellable and serious policy proposals, finding effective language with which to sell those proposals (“tax relief,” “the death tax”), and keeping wavering Republicans on board. (There is no analogue to Grover Norquist’s anti-tax pledge in the health care space.) A debate over whether America should move towards high deductibles and catastrophic insurance would be a valuable debate to have. There are real arguments for the conservative position on this issue. But it's not the debate we're having, and that's because conservatives are too scared, and too divided, to have it.

To: Lane3 who wrote (41516)	3/28/2017 8:58:56 AM
From: Lane3	Read Replies (1) \| Respond to of 42652

The Next Progressive Health Agenda Paul Starr March 23, 2017 This is the second part of a two-part article. Part I is here. The full version appears in the Spring 2017 issue of The American Prospect under the title: “The Republican Health-Care Unraveling: Resist Now, Rebound Later.” This is the “rebound” part. Subscribe here to the magazine. Even as they resist the Republican rollback of the ACA and Medicaid, Democrats should be thinking about new initiatives in health care. No doubt the next steps will depend in part on what Trump and the Republicans end up doing. In the wake of federal legislation, many of the critical decisions in the short run may move to the states. But Democrats cannot limit themselves to defensive efforts to salvage the ACA at either the federal or the state level. They need to think about a more attractive national agenda in health care that reflects the lessons of the ACA and new political realities. The coming national Democratic debate is going to focus on extending Medicare—to whom, how quickly, and under what rules will be the questions. The strategy for universal coverage in the ACA relied on the extension of Medicaid for the poor, but the limitations of that approach should now be clear. In its 2012 health-care ruling, the Supreme Court effectively made it impossible to use Medicaid as a foundation for universal coverage. As a mixed federal-state program, Medicaid affords states the opportunity to limit coverage, and the ACA experience has shown how far red states will go in doing that. Republicans may also succeed in eliminating Medicaid’s status as an entitlement, which will be hard to restore. As a national program with deeper public support as an entitlement and no role for the states, Medicare does not suffer from these problems. When Medicare was enacted in 1965, its backers hoped to use it to cover other groups besides seniors, and in 1972 Congress did extend it to the disabled and patients with end-stage renal disease. (The disabled become eligible for Medicare two years after they qualify for federal disability insurance, a delay that leaves many people with high costs in the individual market.) But the expansion of Medicare then stopped, and in the 1980s Democrats in Congress obtained Republican support for incremental expansions of Medicaid to cover low-income pregnant women and young children. This was the path that led to the ACA’s further Medicaid expansion, a strategy that the Supreme Court and Republicans have now brought to an end. Many people will equate an expansion of Medicare with a “single-payer” plan. But even Medicare-for-all would not be a single-payer system since about one-third of current Medicare beneficiaries use the program to buy coverage in a private Medicare plan. Medicare today is a marketplace—but a marketplace with a dominant public plan and not just a “public option,” which might turn out, if badly designed and established separately from Medicare, to be a relatively small and weak player in the market. Medicare-for-all faces two enormous obstacles. Moving everyone under age 65 into Medicare would require a huge increase in taxes; employees who now receive health care as a fringe benefit would inevitably look at those taxes as an additional burden, even if reformers try to assure them that their wages would rise once health care was financed by taxes. Moreover, many seniors insist that Medicare is their program, and they fear—or can be made to fear—that extending the program to others will jeopardize their coverage. They also see Medicare as an earned benefit, and many of them resist extending it to people who they believe haven’t earned it. But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation. But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation. My name for this new program is “Midlife Medicare,” which would be open to people age 50 to 64 not otherwise insured (for example, by an employer). Seniors would be more likely to accept this extension than any other; for one thing, AARP welcomes as members all Americans 50 years of age and older. Earlier versions of this idea have been referred to as a “Medicare buy-in”; I have in mind a program that would be partly financed by taxes and that would automatically provide a basic level of coverage (no mandate needed), which those in midlife could increase by paying income-related premiums (as seniors do now). Midlife Medicare would have advantages for both its beneficiaries and those age 49 and below remaining in the individual insurance market. The enrollees in Midlife Medicare would benefit from the countervailing power that Medicare exercises. Medicare pays provider rates that are substantially below those paid by private insurers in the non-Medicare market, yet providers accept Medicare patients, who consequently do not face the “narrow networks” in most plans in the individual and small-group markets. Americans who continue to have employer coverage will have the assurance that if they need to retire early, they will have health insurance as good as they would now get at age 65. Midlife Medicare is also a response to the rising death rates and declining health that economists Anne Case and Angus Deaton have demonstrated among non-Hispanic whites in midlife. Moreover, by pulling the 50- to 64-year-olds out of the individual insurance pool covering people 49 years of age and under, Midlife Medicare would make coverage for the younger population substantially cheaper. The younger enrollees in the individual market would, in effect, no longer be shouldering part of the cost of the more expensive 50- and 60-year-olds. This is a much better way to reduce rates for 20-year-olds than the Republicans’ proposal to let insurers charge 60-year-olds five times as much as young adults. An additional step to relieve the burden on the individual market would be to eliminate the two-year delay in the eligibility of the disabled for the existing Medicare program. Combining this step with Midlife Medicare and a strong reinsurance program would stabilize and make coverage in the individual insurance market significantly less expensive. With these measures in place, the system could be more or less workable even if Republicans eliminate the individual mandate in favor of a 30 percent premium surcharge on individuals who fail to maintain continuous coverage (as the Ryan bill would do). Although I don’t think that would be a good thing to do, I also don’t think Democrats want to focus their next health agenda on restoring the individual mandate. Formulating a new health-care agenda requires acknowledging that although the ACA has done much good, it has not worked out as well as its supporters originally hoped. The Supreme Court and the red states have limited how far the strategy could go in achieving health care for all. High deductibles and narrow networks have meant that many people are unhappy with the coverage they are receiving. Trump and the Republicans cynically played on public dissatisfactions, suggesting they would provide something better when, in fact, their alternatives would intensify the problems Americans face. We need to move in a more promising direction that takes into account the difficulties that progressive reform has long faced in health care. Midlife Medicare could be a big next step toward a system that works better for everyone.