pre-existing conditions

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.

 

 

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.