Medicare-for-All Debate Reflects Voter Interest in Health Care

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Medicare-for-All has become a campaign battle cry, even though what it actually means is far from clear.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

First off, the Medicare-for-All version espoused by Vermont Senator Bernie Sanders isn’t actually an extension of Medicare, which now covers 50 million Americans, but would be phased out over four years. His bill contains provisions, such as coverage for long-term care, that aren’t covered now by the landmark health insurance plan created in 1965. Sanders is short on details of how to pay for more robust and costly benefits.

Most advocates of “Medicare-for-All” are expressing support for a single-payer system under which the federal government would assume the role of a giant, publicly funded health insurer. Sanders and others want to see expanded coverage for current Medicare enrollees as well as universal coverage. An enlarged pool of patients under a Medicare-for-All system would give government officials even more leverage to negotiate lower and more consistent pricing for medical services and prescription drugs.

Elimination of all private insurance, including insurance policies provided through employers, has been branded as “socialism” by Medicare-for-All opponents. For context, opponents said the same thing about Medicare.

Some Medicare-for-All proponents would like to see an expansion of Medicare eligibility and benefits, but not necessarily elimination of all private insurance, which provides coverage for 150 million American workers and their families.

Democrats who pushed through the Affordable Care Act (ACA) in 2010 made a similar political calculation, though they stopped short of including a “public option” that would have provided a government-sponsored health insurance plan. Instead, they opted for expanding Medicaid eligibility on a cost-sharing basis with states.

Some present-day Democrats, including House Speaker Nancy Pelosi who steered the ACA through Congress earlier this decade, still prefer an incremental approach as the logical and politically achievable next step towards universal health insurance. That might involve increased federal funding for Medicaid expansion, restoration of the mandate for everyone to have health insurance coverage or creation of some form of reinsurance pool to smooth out the cost of high-cost patients.

These variations, combined with 23 Democratic presidential candidates running around the country talking about health care while attempting to differentiate themselves from the herd, have created understandable confusion among voters. That confusion is compounded by continuing efforts by the Trump administration to take the ACA (Obamacare) off the books.

What’s clear is that some provisions of the ACA are very popular, notably preventing people with pre-existing conditions, often chronic illnesses or cancer survivors, from being denied affordable health insurance coverage. That has created a conundrum for congressional Republicans who tried unsuccessfully to repeal and replace Obamacare. Republicans express support for retain the pre-existing condition provision, yet they haven’t successfully landed on a larger platform to address health insurance access – and rising health care costs.

Beyond the debate over Medicare-for-All, health care in America is confusing. There are multiple public players (Medicare, Medicaid, Veterans Health Care, Indian Health Service, public health clinics, hospitals affiliated with public universities, public mental health clinics and public school clinics) and private players (for-profit corporations, nonprofit organizations, medical practices, medical laboratories, hospitals affiliated with private universities and integrated health care systems). 

The divide between health insurance and health care delivery is a blurred line. Many private health insurance policies come with their own networks that limit choice of medical providers.

Adding to this dizzying picture are soaring drug prices, with their own cast of characters that include pharmaceutical companies, pharmacy benefit managers, self-insured corporations, foreign-based internet retail outlets and prescription drug patent attorneys.

The end result is a health care system that is costly, suffers from a lack of coordination and isn’t equitable. One report concluded, “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.” 

Oregon has pioneered approaches to health care that respond to broader criticisms of the US system, or lack of a “system.” Under a federal waiver, Oregon has promoted increased in-home care for older adults and physically disabled persons that enables independent living and avoids more expensive institutional care. Oregon was among the first states to expand Medicaid eligibility, as permitted under the ACA, and has steadfastly defended that expansion despite rising costs.

Former Governor John Kitzhaber implemented coordinated care organizations serving low-income Oregonians to “bend the cost curve” through innovation and coordination. Since leaving office, Kitzhaber has pushed for investing to redress “social determinants” of health such as a lack of proper nutrition and early childhood education. Health care systems are striving to integrate physical and behavioral care to improve outcomes.

The Washington Legislature enacted this year a first-in-the-nation state-sponsored long-term care social insurance program. Under the program, Washington residents will pay 58 cents on every $100 of income, with the revenue flowing into a Long-Term Care Trust. Residents who pay into the fund for 10 years (three if a catastrophic disabling event) will be entitled to receive $100 a day up to a lifetime cap of $36,500. The money can be used for in-home care, installation of accessibility ramps, home food deliveries or transportation. The payroll tax is projected to generate $1 billion per year.

For many health care observers, actions such as Oregon’s and Washington’s are akin to bailing water out of a sinking boat. They call for a broader, more holistic approach to reform. That isn’t the same as calling for Medicare-for-All, which remains somewhere on the political spectrum between an aspiration and an abstraction.

What seems inevitable is that Americans have grown restive with gridlock as health care out-of-pocket costs and drug prices continue to rise much faster than inflation or wages. The 2018 mid-term election, which saw Democrats unseat GOP congressional incumbents and capture Republican-dominated seats, could be a bellwether of growing voter interest in tangible action on health care. Most prominent Democratic 2020 presidential candidates have apparently heard that message, which accounts for their support for Medicare-for-All or something like it that is significant and meaningful.



Schrader Offers Democratic Plan to Repair Obamacare

Oregon Congressman Kurt Schrader and nine other House Democrats offered what they called “real, concrete solutions” to cracks in Obamacare’s individual market health insurance. The plan won’t go anywhere until it’s clear whether Senate Republicans have enough votes to pass their own Obamacare replacement bill, with a vote expected next week.

Oregon Congressman Kurt Schrader and nine other House Democrats offered what they called “real, concrete solutions” to cracks in Obamacare’s individual market health insurance. The plan won’t go anywhere until it’s clear whether Senate Republicans have enough votes to pass their own Obamacare replacement bill, with a vote expected next week.

Led by Oregon Congressman Kurt Schrader, 10 House Democrats have floated a plan to fix Obamacare as Senate Republicans prepare to vote on a revamped alternative that still slashes Medicaid spending by $700 billion.

Schrader said the House Democratic plan proposes “real, concrete solutions that will stabilize and improve the individual market, making Obamacare work better for everyone and getting us closer to universal coverage for all Americans.”

One of the key elements in the Schrader proposal is a $15 billion annual reinsurance fund to pay health insurers that enroll higher-cost, sicker individuals. Obamacare contained a similar reinsurance fund from 2014-2016. The concept is to ease the cost burden for insurers of expensive care for some patients so average premiums for participants in the individual market can be lowered.

Other features include continuation of payments to insurers that offer discounts to low-income patients, changing the enrollment period from November to May to coincide with when taxpayers receive income tax refunds and expanding tax credits for buying insurance based on age, geography and income. The plan calls for robust marketing of health plans with subsidies and drawing bidding areas that provide more competition for underserved rural areas.

"Although we’ve made progress, Members of Congress have to acknowledge that too many Americans still struggle with costs, especially people in the individual market," Schrader said.

Schrader and his colleagues also would allow people nearing retirement age the option to buy into Medicare coverage and permit younger adults to purchase catastrophic health plans that include primary care coverage with anticipated lower premiums.

Oregon Senator Ron Wyden urged a bipartisan approach to stabilize the individual health insurance market. He also encouraged steps to lower prescription drug costs, such as allowing Medicare to negotiate drug prices with pharmaceutical companies.

The first inklings of Democratic willingness to work on cracks in Obamacare came after Senate Majority Leader Mitch McConnell indicated that if a GOP alternative fails to pass, the only avenue left is a bipartisan approach. President Trump and political conservatives have said failing to repeal and replace Obamacare would break a longstanding Republican promise. Kentucky GOP Senator Rand Paul has announced he will oppose the GOP health care bill because it doesn’t go far enough toward repealing Obamacare provisions.

Meanwhile, GOP moderates are worried about the impact of large cuts to Medicaid on elderly and disabled Americans, who consume the largest amount of Medicaid funding. In the revised version of the Senate health care bill, more money is set aside to combat the national opioid crisis in a play to win over some wavering Senate moderates, but it still might not be enough.

Maine Senator Susan Collins, one of the moderates unconvinced by the redrafted plan, pointed out there is a $70 billion math error. The Better Care Reconciliation Act includes an amendment by Texas Senator Ted Cruz that would allow bare-bones health plans also provides $70 billion in federal support for health insurers. Except the $70 billion Cruz would use for this purpose is already allocated in the bill. Tim Jost, a health care law expert and professor at Washington and Lee University, told MSNBC that the bill “gives an additional $70 billion to the states and then the Cruz amendment gives it to insurers that offer compliant plans in addition to noncompliant plans.”

Congressional Republicans are using the budget reconciliation process to replace Obamacare because this procedural is not subject to Senate filibuster rules. But the 52-member Senate GOP majority is thin and only can afford to lose two members to pass its health care legislation. Senate Minority Leader Chuck Schumer has said Democrats would work with Republicans if they dropped the reconciliation process. According to The Hill, some Republican senators, including Lindsey Graham, have entertained informal conversations with Democrats about a bipartisan legislative approach.

The GOP-backed American Health Care Act passed the House earlier this year with a narrow 2-vote margin. The changes under consideration in the Senate, including retaining two taxes imposed by Obamacare, might erode that margin and make a reconsideration vote in the House uncertain. House Minority Leader Nancy Pelosi has not offered to work with Republicans on Obamacare-related legislation. Pelosi did say the Schrader-led proposal offer “promising ideas to put solutions over politics to strengthen the Affordable Care Act and continue to lower costs for seniors and hard-working families.”

Senate To Turn into Three-Ring Circus Over Health Care Legislation

More Capitol Hill drama as Senate Majority Leader Mitch McConnell is pressing for a vote before the July 4 break on an Obamacare replacement, as fellow Republicans balk at the lack of any pubic process, hearings or debate and Democrats gird to shut down Senate business.  Photo Credit: J. Scott Applewhite/AP

More Capitol Hill drama as Senate Majority Leader Mitch McConnell is pressing for a vote before the July 4 break on an Obamacare replacement, as fellow Republicans balk at the lack of any pubic process, hearings or debate and Democrats gird to shut down Senate business.

Photo Credit: J. Scott Applewhite/AP

You can exhale because there shouldn't be any Capitol Hill activity this week on President Trump and possible collusion in Russia. But take a deep breath as the Senate moves toward a highly contentious and audacious pre-July 4 vote on a health care bill that still hasn’t seen the light of day.

Senate GOP leaders reaffirmed plans to bring forward an Obamacare replacement measure in the next two weeks as Senate Democrats promised to bring all legislative action to a screeching halt, starting with talk-a-thon Monday night to list the deplorable provisions anticipated in the still-secret Republican bill.

Reports circulating on the Hill indicate there isn’t a consensus among Senate Republicans on key issues such as the level of Medicaid spending, addressing the national epidemic of opioid addiction and lowering health insurance premiums under the new plan for patients with pre-existing conditions. Senate GOP leaders have implied the bill, being drafted by a small workgroup behind closed doors, will get a vote whether or note there are enough votes for it to pass.

A website carried an elaborate explanation of how Senate Majority Leader Mitch McConnell might even might manage to limit floor debate when the GOP health care bill emerges from the work group. According to the explanation, McConnell could put a placeholder bill on the Senate floor calendar and let it suck up most of the 20 hours of allowable debate time. The real plan would be introduced as an amendment with little time left for a drawn-out floor debate.

Whatever the procedural strategy is, criticism is building for addressing contentious and emotionally charged health care legislation without a public hearing. The House, before it narrowly passed its version of an Obamacare replacement, didn’t hold any public hearings. It did come to the floor our of House committees, however, which apparently won’t be the case in the Senate under the current legislative scenario.

The secretive bill-writing strategy probably relates to the unpopularity of what the House passed, as reflected in public opinion polls and in raucous town hall meetings held by GOP lawmakers who voted for the bill. Trump, who initially praised the House bill, has since called it “mean" and urged senators to be more “generous.”

It doesn’t appear all Senate Republicans, including Florida Senator Marco Rubio, is on board with rushing a health care bill through a floor vote without any hearings and little debate. However, Senate GOP leaders are telling fellow Republican caucus members, this may be the one and only chance to vote to repeal Obamacare – a promise seven years in the making – before moving on to other legislative priorities.

Unlike the House, Senate Republicans want to have their heath care bill scored by the nonpartisan Congressional Budget Office before a floor vote. Reportedly, pieces of the new legislation have already been shared with CBO, though no results have been disclosed.

Democrats are doubtful that whatever emerges will be generous enough. They are hatching their own procedural strategies, including objecting to all requests to proceed with business on the Senate floor that requires unanimous consent or 60 votes to continue. Another tactic will be an attempt to force the referral of the House-passed American Health Care Act to a Senate committee.

Both sides will be frequently in front of microphones at press conferences and active on social media. Senators Bernie Sanders and Elizabeth Warren held a Facebook Live event to whip up opposition. Other Obamacare repeal opponents are urging a flood of emails and other constituent communications to sweep into Senate GOP offices.

Last week, Vox ran a story based on interviews with eight Senate GOP senators in which none of them seemed to have a glimmer of an idea what was in the Republican health care plan or the policy rationale for the provisions they couldn’t articulate. Those may be hard perceptions to shake if the Senate springs its health care bill for a vote with little notice and virtually no debate.

'Obamacare’s Kindest Critic'

Obamacare has been assailed from the political right and left, but its namesake took an unusual step in publishing a critique that suggested ways his legacy achievement could be perfected and expanded.

Obamacare has been assailed from the political right and left, but its namesake took an unusual step in publishing a critique that suggested ways his legacy achievement could be perfected and expanded.

Republicans are convening in Cleveland this week and can be expected to bash Obamacare nonstop, but constructive criticism of the Affordable Care Act came last week from an unanticipated quarter – Barack Obama.

Signing his critique as Barack Obama, J.D., the President described how his legacy achievement could be perfected by adding a public health insurance option and allowing Medicare to negotiate prescription drug rates, which is currently prohibited.

The New York Times called Obama “Obamacare’s kindest critic” and said his suggestions have the appearance of a memo to his hoped-for Democratic presidential successor, Hillary Clinton.

“Presidents usually wait until their memoirs to review their work,” the Times editorialized, but in this case Obama used the sixth anniversary of the act to make observations about his handiwork in the Journal of the American Medical Association. "Health care costs are still too high, he wrote, and 29 million people still lack coverage.”

One of Obamacare’s “failings” is an incomplete expansion of Medicaid in 19 states that chose not to accept federal financial assistance to pay for expanded coverage.

But Obama points to the actual failure of providing coverage for 9.1 percent of the U.S. population. Obamacare reduced that total from 16 percent, but there are still people who can’t afford health care, often because they lack the money for co-pays and deductibles in addition to health insurance premiums.

Unsuccessful Democratic presidential candidate Bernie Sanders campaigned hard on a Medicare-for-all health insurance plan that captured a lot of attention and rekindled interest in a single-payer system. Obama’s recommendation to add a public option to the health insurance exchange is a more targeted version of the idea, which possibly could win bipartisan support if aimed at rural areas with few private-sector health insurance choices, the Times said.

Clinton has expressed support for a public option. The Times notes Clinton has also voiced interest in allowing Americans between the ages of 55 and 64 to enroll in Medicare.

The Obama view on Obamacare is that it isn’t going away any time soon, but it should be improved and perfected as part of a continuing drive to put a blanket of health insurance coverage over all Americans.

Not everyone agrees. Leading Republicans continue to call for repeal of Obamacare and replacing it with something else, which has largely been ill-defined. The Obamacare health care exchanges are under pressure as costs continue to rise and some insurers lose money. Efforts in Oregon and elsewhere to promote coordinated care and integration of physical and mental health care have registered some positive results, but are still in an extended trial stage. Employers have largely retained private health insurance coverage for employees, but have blunted cost increases by opting for plans with higher deductibles and co-pays and trimmer provider networks.

“What Mr. Obama has done is unusual – asking someone else to burnish a legacy of which he is personally proud,” the Times said. “If the candidates (and Congress) pay attention, his request may also do a world of good for millions of Americans for whom decent health care remains out of reach."

The Search for an Obamacare Alternative

Congressional Republicans have failed so far to offer a comprehensive alternative to Obamacare, but there is a surge of support on the campaign trail to look at a single-payer health care system.

Congressional Republicans have failed so far to offer a comprehensive alternative to Obamacare, but there is a surge of support on the campaign trail to look at a single-payer health care system.

While congressional Republicans continue to look for an Obamacare replacement, others are stepping up with alternatives they may like even less but may appeal to a significant segment of the U.S. population.

Democratic presidential candidate Bernie Sanders has been a consistent voice for a single-payer national health care system, which could be a simple as having everyone enrolled in Medicare. His support for a single-payer health care system is credited by some political observers for his strong showing in early Democratic presidential polls as he challenges Hillary Clinton, who also has a reputation for health care reform.

The single-payer system Sanders has supported on the presidential stump is estimated to cost $15 trillion over 10 years. But Sanders and like-minded supporters say a single-payer system would eliminate $5 trillion in “administrative waste" in that same period. The plan would be paid for by what is described as a “progressive” payroll tax

A Colorado group has placed Initiative 20 on that state's 2016 general election ballot to create ColoradoCare. Under this universal health care coverage proposal, people who live or earn money in Colorado could choose their providers, but medical bills would be paid by the state.

Backers of the Colorado initiative would pay for ColoradoCare through a 10 percent payroll tax, which would generate an estimated $25 billion per year. Under the plan, employers would pay two-thirds of the 10 percent payroll tax and employees the remaining one-third. Self-employed individuals would pay the entire 10 percent on their net income, according to The Denver Post.

The concept of a national single-payer health care system has been floated before and generally beaten back because of fears of an even larger federal bureaucracy, increased health care costs and higher taxes. Hillary Clinton’s proposed health care reform measure stopped short of a single-payer system, as does the Affordable Care Act, which tries to reduce the number of people without health insurance by creating a government-managed marketplace.

While it is easy to point at warts in Obamacare, it is much harder to come up with a plan to replace it, which is why congressional Republicans have voted scores of times on repeal and zero times on a substitute. One reason for the difficulty is that the U.S. health care system has lots of parts. There is the part where workers and their families receive health insurance offered through their employer. Then there is Medicare, Medicaid, the Veterans Administration, Indian Health, federally funded clinics, school clinics, psychiatric care and alternative care such as naturopathy and chiropractic.

The complex health care system and health insurance coverage only partially overlap, which sometimes leads to awkward and expensive health care delivery, such as children from low-income families being forced to seek care in a hospital emergency room instead of a school clinic or people suffering from mental illness receiving prescriptions for psychotropic drugs from primary care physicians.

One of the underlying appeals of a single-payer system is its promise to consolidate the silos in the health care delivery system and eliminate (or at least shrink) the disparity between health care delivery and health insurance.

Skeptics question whether a single-payer health care system would live up to its promise in the United States, where many people are accustomed to a broad range of choices in providers and some providers decline to serve patients in a public health program because of lower fees. Skeptics also doubt Americans are willing to pay higher taxes and hand over more control of their lives to the federal government.

While those arguments have prevailed in the past, progressives such as Sanders and the Initiative 20 backers in Colorado are saying that tinkering with the health care system is not enough to stem rising health care costs and ballooning insurance premiums. They say if you want an alternative to Obamacare, here’s one to consider.

In the absence of another comprehensive alternative, the single-payer system appears to be gaining some momentum as a policy option.

Wyden Walks Medicare Policy Tight Rope

His Medicare reform white paper co-authored with GOP presidential running mate Paul Ryan has Democratic Oregon Senator Ron Wyden in the political crosshairs of just about everybody.Democratic Oregon Senator Ron Wyden, who isn't even on the ballot this fall, nevertheless finds himself in the middle of a hard-fought, negative presidential campaign. And he isn't happy about it.

Wyden co-authored a provocative white paper on Medicare reform options earlier this year along with House Budget Chair and now GOP presidential running mate Paul Ryan. The Mitt Romney-Ryan campaign seized on the white paper — and Wyden — as evidence of bipartisan support for their approach to Medicare reform.

Wyden has gone to great pains, including a speech this week to the Portland Rotary, to say ‘no dice.’

Defending the white paper and his collaboration with Ryan, Wyden says what Romney has endorsed and House Republicans have passed is not consistent with the white paper's approach to "preserve the Medicare guarantee."

In an interview with Ezra Klein of The Washington Post, Wyden said the major differences between his views and those of Romney involve the Affordable Care Act and Medicaid. Romney and Ryan favor repeal of the Affordable Care Act and Wyden doesn't. The Ryan-inspired House budget would give states more freedom to run their Medicaid programs for low-income citizens, but also provide less money. Wyden says that will harm lower-income seniors who qualify for both Medicare and Medicaid.

The Super Secret Committee

The Super Committee has a lot riding on its shoulders, but so far the horse hasn't left the barn. Photo by Kelly Canfield.The 12-member congressional Super Committee has until Thanksgiving to come up with another $1.2 trillion in federal spending cuts. Since it deliberates behind closed doors, no one really knows whether it is making progress or spinning its wheels.

So the best you can do is look for clues. One top House GOP lawmaker suggested the $1.2 trillion in savings could come entirely from health care reductions.

Congressman Denny Rehberg, R-MONT, who chairs the House Appropriations subcommittee that deals with health care spending, said the savings could be achieved with two simple modifications to the federal health care reform law adopted last year. One change would knock out proposed Medicaid expansion; the other would trim subsidies to help people buy health insurance.

At the same time, the Wall Street Journal reported that nearly 50 percent of Americans live in households that receive some form of federal aid. Almost 35 percent are in households receiving food stamps, subsidized housing, cash welfare or Medicaid benefits. Almost 15 percent receive Medicare benefits and nearly 16 percent receive Social Security benefits.

Oregon Leads Way on Heath Insurance Exchange

Oregon received good news this week when the U.S. Department of Health and Human Services (HHS) announced “Early Innovator” grant awards to seven states that will lead the way in developing pilot health insurance exchanges, as part of the major health care reform legislation approved by Congress last year.

President Obama will be in the Portland area Friday to tour Intel and can be expected to say more about the grant while here.

The Oregon Health Authority will receive $48 million to design and implement the information technology (IT) infrastructure to operate an exchange. Consumer-friendly and efficient IT infrastructure will be a key component to ensure exchanges are a place where individuals and small employers can shop for, select and enroll in high-quality, affordable private health plans.

The New Elephant in the Room

Oregon U.S. Rep. Greg Walden’s ascension to House Leadership marks the first time in decades an Oregonian has held such a high-ranking position in either the House or the Senate. Photo by House GOP Leader.As expected, the Democrats suffered a crushing defeat in the House last Tuesday, losing more than 60 seats and losing control of the chamber to the Republicans. The GOP gains exceed those made during the Republican wave of 1994 when the party picked up 54 House seats.

Not since 1948 has the party made such monumental inroads. With 218 seats needed for a majority, Republicans so far have officially won 233, while Democrats have won 174.

The news was better for Democrats in the Senate, though still not good. Despite losing six seats (with two still too close to call), Senator Harry Reid of Nevada, the Democratic leader, narrowly prevailed and his party hung onto control by winning hard-fought contests in California, Delaware, Colorado, Connecticut and West Virginia.

The more notable impact on Oregon from the national election is the shift in power to Congressman Greg Walden (R-OR). While Earl Blumenauer and Peter DeFazio have enjoyed powerful majority Committee posts during the last four years, their roles now will be marginalized as they settle into the new Democratic minority. House rules allow for little influence from the minority.