On one hand, I'm always torn when it comes down to issues like this. I'm absolutely a Medicare for All proponent and was a Sanders voter in the 2016 and 2020 primaries. Healthcare reform is immensely important to me as a mother of a child with ASD, the wife of a Marine vet who relies heavily on VA care and a woman-of-color with chronic diseases, myself. We live in TN which, to many peoples surprise, has an excellent Medicare system (TENNCare) though it is sadly facing cuts and lapses thanks to the so called BBB of '25. It never fails to shock me how the people of TN can vote overwhelmingly for the party that wants to do the most damage to such systems when such a large percentage of those same voters benefit from those same systems.
That said: I totally get that these kinds of sweeping reforms can only happen with a strong change of political power, governance and tons of reform, all of which is hard to manage in our current political environment. So I very much understand those who are drawn to candidates who have proven themselves to be hard working deal brokers, with less focus on loaded, polarizing issues like universal healthcare. We need to take power back, first and foremost.
Michiganians don't face an easy choice, imo. I hope that whoever wins the primary is able to ultimately keep the seat for the Dems because losing it would bode will for 2028, to say the least.
Then again, living in TN, I also envy the people of Michigan having these kinds of choices/opportunities at all, ngl.
((p.s. To those who say the transition to universal health insurance like Medicare for All would be chaotic, disruptive and difficult: It will absolutely be a rocky transition, yes, but ffs, they managed to make the switch in England post WWII while still under long-lasting wartime rationing and the like.))
Thanks, Jonathan: Tommy Douglas served as the Premier of Saskatchewan from 1944 to 1961 and led the creation of Canada's first universal public healthcare system, earning him the title "Father of Medicare." In 1947, Hospital Insurance introduced the Saskatchewan Hospital Services Plan, making general hospital care free or low-cost for all residents. Saskatchewan got affordable health care. It was so popular that the federal Liberal Party took the program and made it nationwide. Thanks to Premier Tommy Douglas, we have a fairly good health care system today, although the private health care industry is trying to take out various options. Just keep the profiteers out of health care. Its doable
Medicare for all is where we should be as a country. But the best we could do as of now was Obamacare, some years ago. Not what we wanted, and has been under assault ever since- and never more than now, than in Trump 2.0. All true. And now, this is the hill El-Sayed is prepared to die on. I think he might have chosen a better year. I do note, as well, he's not a graceful winner. Up 15 points in recent polls, still chooses to punch down, as in a recent podcast. "AIPAC looked around for the least capable senate candidate anywhere and chose to help my opponent, Haley Stevens." Also, Black voters in MI are an important bloc that any candidate should court. A Black prominent Detroit minister recently said of El-Sayed "He is a one hit wonder more worried about Palestine than Detroit." Stevens has a track record of playing well with other children. So to speak. Where is El-Sayed's? MI voters must vote with one thing and one thing only in mind: Dems must take the senate. No other beautiful dreams will be within reach otherwise, for a very long time to come. Including MFA. Even though many of us would like to see its eventual passage. But you can't get there from 2026. Too much more work lies ahead.
I hear all this talk about how Stevens is the more electable candidate, but for Pete's sake, if you can't win a primary, then you're not electable at all. And the fact that she's taken $60 million from AIPAC has me questioning her ability to fundraise. It's not like AIPAC is going to continue funding her campaign against Rogers, who is also pro-Israel.
I understand that. But if Stevens can't win the primary, then her electability in the general election is moot. I feel the same way when I hear people speculating about how Bernie Sanders would have beat Trump in 2016.
i've spent the weekend binge watching the west wing and crying.
one of the recurring themes was this same tension between electability and remembering why these guys said they wanted to run.
on tv at least, when they tried to tack to the safe middle their approval ratings went down, and when they 'let bartlett be bartlett' (actually fight for food and health care and good education, the polls went up.
national politics is no longer carried out here in reality, so maybe a tv show has some wisdom for the dems.
Now that baby boomers have retired I'd say they're more likely to vote for benefits for themselves and not for everyone else. So I suspect any kind of universal health insurance proj will be a non starter for an easy decade if not longer.
After that as we learned from Obamacare. If it doesn't seem free to people. They'll never support it.
This means somehow magically the group healthcare benefits folks now have need to translate 1 to 1 over to the new system, and all the uncovered or partially so have to see no out of pocket new costs of just about any kind.
Exactly where we can hide all of it, no idea but there's plenty of to be thinking it through.
Steven’s loves Israel (that has free education & healthcare) more than the US. She’s told us this. Why would anyone expect her to help the people here, when she’s devoted to a foreign country?
The people of Palestine are being ethnically cleansed and genocided. Caring for those that are suffering is merely the moral choice. Why would anyone choose to support evil?
The “ for all” is the MOST important part of Abdul's slogan. Sure Medicare if we get there, but policies dedicated for all our communities well being, and not toward hate and violence sponsored with our $ and legislation.
I have read from one independent media source, perhaps another writer on The Bulwark, that Medicare for All can’t be afforded. I don’t remember the details, but a good case is made for not being able to pay for Medicare for All. I don’t think much of anything in the way of new legislation that involves spending can be passed without rescinding the tax structure that effectively lowered taxes on the rich. Small changes in payroll taxes would go a long way toward securing both Social Security and Medicare. Tax policy is hard unless you have a Republican President like Trump who favors the rich for obvious reasons, and control of both branches of the legislature. Reforming tax policy that changes tax rates for the rich, taking away the bonus the Republicans (Trump) enacted may be hard to get past a Trump veto. Changes in the idea of Medicare for All have to be incremental. Whoever wins the nomination will be subject to vicious attack ads from the Republican Party candidate. I think El-Sayed is more vulnerable, but I live in Alabama, where we don’t have to concern ourselves about the direction of our state. Anyone with a D behind their name stands no chance. The D may as well stand for defeated.
I am a lifelong Democrat who has never voted for a Republican. I am a big fan of Medicare for seniors because, let's face it, most of us are essentially uninsurable once we hit 65. But in general, I do not think we should do things in the public sector that can be handled competently in the private sector (with of course guardrails in the form of appropriate regulation and antitrust enforcement). And so while I completely support the idea of universal health insurance as a matter of good policy, does that really require a Medicare for All approach? How's that been going for Great Britain?
At the time of the Obamacare debate, I read T.R. Reid's book, The Healing of America. Everyone should read that book. We need some honest and open debate about the relative advantages and disadvantages of the systems Reid sampled. I for one would put my money on Switzerland's approach. I think we need to let go of our attachment to the employer-based system of health care. Why should employed individuals have better options than the self-employed? Put everyone in the individual market, introduce real competition among insurers by drastically increasing their number, and let actual competition drive down rates. Take that burden off of our small businesses. Make the patient the actual customer of the insurance company, not his/her employer, which would enable plans tailored to the patient's needs and greatly enhance responsiveness to patient concerns.
“ Make the patient the actual customer of the insurance company, not his/her employer, which would enable plans tailored to the patient's needs”. - person young and healthy, takes no insurance; grows older and sick, now wants insurance - yes, this is tailored to the person’s needs but is also economically unsustainable.
Under the Swiss system, everyone -- including the young and healthy -- is required to buy insurance. An "individual mandate" if you will. So adverse selection is not a problem.
At one point during my working life, my employer decided to squeeze down the plan options so that employees were effectively coerced into a managed care plan (so, no PPO option). I had to self-insure my own primary care for a 5-year period, and use the employer plan as effectively "cat cover." I was fortunately able to get adequate coverage for my two children under the new plan. That episode really drove home the fact that I, as the patient, was not the customer. The employer was.
I was under the impression that the biggest opposition to Obama Care came from the mandate that you have to buy insurance.
Where my mind is at is that the free market (not really free as it is today, but that is for another day) can’t do many things well, and there is the idea of public goods. E.g., India decided that digital identity and digital payments are a public good, and so provided both. No Visa or Mastercard, but various apps built on a public Unified Payment Interface (UPI). These leads to the idea of a public digital infrastructure — the modern equivalent of the roads and highways.
The latest news is: According to Press Information Bureau, “Government of India has signed Memorandum of understanding (MoU)/ agreements with 23 countries for sharing or cooperation on India Stack / Digital Public Infrastructure (DPI).”
I don’t see why a basic standard of medical care cannot be a public good. Someone might be happy with the street their house is on being owned by a corporation because the free market is better as an ideological position. I would say, what works in real life often confounds ideology.
I guess we just disagree about the relative merits of free enterprise. I for one think it's a big part of what has made America such an extraordinary economic success.
In terms of the individual mandate, I believe it still exists, but the first Trump administration eliminated any penalty for noncompliance in 2017 in an effort to undermine Obamacare in the hopes that it would collapse of its own weight. But amazingly it didn't.
Young, healthy adults should not fool themselves that they won't end up paying just as much for a "Medicare for All" option, one way or another. At least under a Swiss model, they can tailor their coverage to suit their needs, with say, higher deductibles to keep premiums down. And we would want to keep those essential Obamacare features we tend to take for granted today, such as elimination of pre-existing conditions and lifetime benefit caps.
not if billionaires and corporations paid their fair share.
the context for all of this is this: in the last forty years 170 trillion dollars of wealth moved from the 90% to the epstein class.
more context: fifty years ago, mobil oil suppressed their own study which found that if they kept going as they were we would end up with the clmate disaster we have.
taxpayers paid for being screwed over with subsidies and tax breaks and other legal ways the rich found to keep from paying their fair share.(remember warren buffet said his secretary paid taxes at a higher rate than he did).
now their spending is enough to make it look like consumer spending hasn't fallen, while half the country has to decide between food for their kids or gas to get to work.
so, yeah, those folks watching their schools and hospitals tank might 'end up paying just as much for a "Medicare for All" option' ... but only because the billionaires have warped the system to make that happen.
Yes, indeed, the large employers have enormous bargaining power. And that is precisely the problem. Those discounts then get effectively subsidized by the individual market. We should not be creating two different classes of insureds, one favored and one not. And with more competition, everyone should be able to get the more favorable terms.
How many independent health care insurers are out there now - I believe the market has been consolidating. How would you bring back competition? How would you make it efficient for a physicians’ practice to deal with a hundred different insurance companies?
Good point about market consolidation. We do not have enough health insurance companies at the moment to populate a Swiss model. I believe it would take government intervention in the short term to incentivize more insurers to enter the market. Perhaps as part of an interim solution, the large insurers could be persuaded to offer a greater variety of plans while we transition to a more competitive carrier marketplace.
And you make an excellent point about doctors' offices having to cope with too many forms. I believe the Swiss had an answer for that, which Reid covered in his book, but out of laziness, I just googled the question, and came up with this answer: Swiss health insurers are required to use standardized billing structures and uniform data formats set by federal law. Key elements include uniform tariff codes, standardized electronic data formats, and identical basic benefit catalogs.
So standardization is key. You are absolutely correct.
The problem for a Swiss model is that, by default, health insurance (and the practice of medicine) is regulated by the states in the US. ERISA at the federal level is an exception, not the rule.
You'd run smack into federalism concerns in the courts.
Such a good point. I only know that the ACA imposed and has somehow managed to navigate a dual regulatory system of oversight for health insurers. The federal government was able to set pre-existing condition bans and minimum essential health benefit rules, for example, while the states have continued to approve plan rates & forms and conduct financial surveillance. So somehow the lawyers drafting the law managed to work that much out, and survive any court challenges. Getting the states to agree on claim forms would admittedly be a herculean task. This would need to be a joint initiative of the AMA and the NAIC, with input from local medical associations and insurance regulators.
Much of the inefficiency in the practice of medicine today is driven by the suffocatingly complex paperwork required by insurers. Fixing that problem would, in and of itself, drive real costs out of the system and improve patient care.
"Medicare for All—a proposed version of universal health care that would have the government cover everybody directly, mostly doing away with private health insurance"
A noble concept but with some inherent flaws that need to be addressed:
* Medicare pays out more than it takes in through premiums and dedicated taxes on payrolls. This is especially true for Parts B and D which is heavily subsidized via other taxes.
* Medicare Advantage (MA) is a scam for insurance companies to be more profitable. MA costs ~20% more than comparable standard Medicare and increases costs for Medicare beneficiaries:
> "The Medicare Payment Advisory Commission (MedPAC) estimates that, in 2025, payments from the federal government to Medicare Advantage plans exceed what spending would have been in traditional Medicare by 20%, which translates into $84 billion in additional spending. Higher payments to Medicare Advantage plans increase total Medicare spending, strain the Part A Hospital Insurance trust fund and drive-up Part B premiums for all Medicare beneficiaries. This raises questions about whether the current payment system provides strong financial returns to insurers at the expense of the federal budget, Medicare beneficiaries themselves, and U.S. taxpayers" https://www.kff.org/medicare/how-medicare-pays-medicare-advantage-plans-issues-and-policy-options/
* Will those of us, including my spouse and myself, who purchase supplemental insurance (not MA plans) through private carriers have the same coverage as Medicare for All?
* Misunderstandings of exactly what Medicare is need to be clarified, and with no political spin:
> "Politicians and many Americans frequently describe Medicare as if it were an investment account: Americans “pay into” the program with their payroll taxes throughout their working lives, and in exchange get benefits when they turn 65. However, this is a misconception for two reasons. First, Medicare is a transfer program from workers to retirees, with current benefits largely being funded by current tax receipts. Second, Medicare beneficiaries over the course of their lifetimes tend to receive more in benefits than they pay in both taxes and premiums." https://paragoninstitute.org/paragon-pic/medicare-enrollees-on-average-receive-far-more-in-benefits-than-they-pay-in-premiums-and-payroll-taxes/
* What doctors earn annually needs to be taken into consideration. It takes time and money to specialize but some specialties are a tad overpaid. Eight specialties have an average salary of over $500k, with one over $600k:
([1] Plastic surgery is composed of two parts: reconstructive and cosmetic. Reconstructive is considered essential while cosmetic is... well... cosmetic. IOW cosmetic surgery is elective, reconstructive is not. IMO, it's the folk with a low body self-esteem seeking surgical enhancements that drive up the average salary.)
OK, but. The current system sucks. We pay far more for healthcare than anyone else in the world while getting 2nd tier results. This has been true for decades. No offense meant, but determining the details at this point should be secondary to moving the healthcare ball forward. A rainbow of opinions from Stevens to El-Sayed on how to get there is fine. If real healthcare reform is the goal, and our reps are not corrupted by PACs, the specifics will be worked out, tried, and adjusted. Things will get better. If we throw up our hands and say we cannot do what every other advanced nation does in one form or the other, they will not.
I'm not offended by a different POV, and the devil is in the already established details. I'm not arguing that the system is good, or even fair to middlin'. In fact I point out a couple specific places that it sucks, bigly, and are in critical need of correction: Medicare Advantage plans and doctors earning outrageous salaries.
Another thing that bites the big hairy meatball when it comes to medical costs are the ads for prescription drugs in all media*. There are only two countries that allow Big Pharma to advertise directly to the consumer:
> "The United States and New Zealand are the only countries that legally allow direct-to-consumer pharmaceutical advertising. (The European Union was furious when Lady Gaga’s Instagram post promoting the migraine drug was visible on the continent, noting it flagrantly violated its ban on direct-to-consumer advertising.)
(* IDK about you but I'm more than sick [pun intended] and tired of hearing "ask your doctor if [the Rx] is right for you." This is especially galling when it comes to meds for a disease or illness that afflicts 1:1000, 1:10,000, and even 1:100,000.)
No matter that there are ads in NZ, med prices are subsidized:
> "People need to pay the standard $5 prescription charge, with exemptions for people:
◾ aged 13 years or under
◾ holding a Community Services Card (CSC), or a dependent child of a CSC holder
(Follow link for more deets, including the point where no co-pay is required at all.)
I agree with you that the healthcare ball must be moved forward with no moving the goalposts or Calvinball from the pols, but without some focus on the existing deets this is close to impossible.
Man do I appreciate Cohn's view of the political landscape. Maybe he has some biases that line up with my own or maybe it's just that he is able to articulate the big picture without bias, but when I read his stuff and hear him on podcasts I don't feel like his underlying message is, "progressives are just children who don't understand the only feasible way forward is to court centrists." It is possible that El-Sayed can't win in the general (though it's certainly possible that he can), but as the Republicans have shown, hammering home a point of view WILL eventually change the perspective of the electorate. There's no point in winning if we're just going to stay on the same political course that brought us MAGA.
Exactly Paul, very well said. The perfect congress would include some centrists with focus on rules and responsibility...but also dreamers with ideals that inspire new generations to join the fight and keep an eye on the prize. We would never have gotten ACA without dreamers like Bernie, forcing the centrists to remember why they were in congress in the 1st place. You do not have to agree with everything a representative says for them to be a valuable force moving the country forward.
No doubt, there's a role for dreamers and gadflies in Congress. However, it's usually a problem when they get access to actual power.
Such folks may help frame the debate, but take the ACA example you mentioned. You might credit Sanders with bringing it to the discussion, but who actually did the hard work and got 'er done?
And bear in mind we're talking about a "reasonable" topic here (health insurance) that reasonable folks can disagree about. Throw in some DSA types that are yapping about doing away with all police and prisons, and, well, let's just say (a) not a good strategy for winning elections, (b) stupid ideas!
I didn't say he did. Indeed, the whole point was that some of his fellow travelers say such things and it muddies the water for him. Let's suppose for the sake of discussion that Abdul is only interested in a (sensible) MFA program; that's his only focus. By associating with others that say they want to do away with the police, etc., it pulls him down, makes him less credible.
That said, it's not like the guy doesn't say some, uh, questionable stuff.
On one hand, I'm always torn when it comes down to issues like this. I'm absolutely a Medicare for All proponent and was a Sanders voter in the 2016 and 2020 primaries. Healthcare reform is immensely important to me as a mother of a child with ASD, the wife of a Marine vet who relies heavily on VA care and a woman-of-color with chronic diseases, myself. We live in TN which, to many peoples surprise, has an excellent Medicare system (TENNCare) though it is sadly facing cuts and lapses thanks to the so called BBB of '25. It never fails to shock me how the people of TN can vote overwhelmingly for the party that wants to do the most damage to such systems when such a large percentage of those same voters benefit from those same systems.
That said: I totally get that these kinds of sweeping reforms can only happen with a strong change of political power, governance and tons of reform, all of which is hard to manage in our current political environment. So I very much understand those who are drawn to candidates who have proven themselves to be hard working deal brokers, with less focus on loaded, polarizing issues like universal healthcare. We need to take power back, first and foremost.
Michiganians don't face an easy choice, imo. I hope that whoever wins the primary is able to ultimately keep the seat for the Dems because losing it would bode will for 2028, to say the least.
Then again, living in TN, I also envy the people of Michigan having these kinds of choices/opportunities at all, ngl.
((p.s. To those who say the transition to universal health insurance like Medicare for All would be chaotic, disruptive and difficult: It will absolutely be a rocky transition, yes, but ffs, they managed to make the switch in England post WWII while still under long-lasting wartime rationing and the like.))
Thanks, Jonathan: Tommy Douglas served as the Premier of Saskatchewan from 1944 to 1961 and led the creation of Canada's first universal public healthcare system, earning him the title "Father of Medicare." In 1947, Hospital Insurance introduced the Saskatchewan Hospital Services Plan, making general hospital care free or low-cost for all residents. Saskatchewan got affordable health care. It was so popular that the federal Liberal Party took the program and made it nationwide. Thanks to Premier Tommy Douglas, we have a fairly good health care system today, although the private health care industry is trying to take out various options. Just keep the profiteers out of health care. Its doable
excellent journalism here. much appreciated!
I'm so torn about Michigan - I want el Sayed to win but I think Stevens is more likely to win the seat in the election 🤷🏻♀️🤷🏻♀️
Medicare for all is where we should be as a country. But the best we could do as of now was Obamacare, some years ago. Not what we wanted, and has been under assault ever since- and never more than now, than in Trump 2.0. All true. And now, this is the hill El-Sayed is prepared to die on. I think he might have chosen a better year. I do note, as well, he's not a graceful winner. Up 15 points in recent polls, still chooses to punch down, as in a recent podcast. "AIPAC looked around for the least capable senate candidate anywhere and chose to help my opponent, Haley Stevens." Also, Black voters in MI are an important bloc that any candidate should court. A Black prominent Detroit minister recently said of El-Sayed "He is a one hit wonder more worried about Palestine than Detroit." Stevens has a track record of playing well with other children. So to speak. Where is El-Sayed's? MI voters must vote with one thing and one thing only in mind: Dems must take the senate. No other beautiful dreams will be within reach otherwise, for a very long time to come. Including MFA. Even though many of us would like to see its eventual passage. But you can't get there from 2026. Too much more work lies ahead.
Great work, thank you for this!
I hear all this talk about how Stevens is the more electable candidate, but for Pete's sake, if you can't win a primary, then you're not electable at all. And the fact that she's taken $60 million from AIPAC has me questioning her ability to fundraise. It's not like AIPAC is going to continue funding her campaign against Rogers, who is also pro-Israel.
This conclusion is flawed - the electorate in a general election is quite different from that in a primary.
I understand that. But if Stevens can't win the primary, then her electability in the general election is moot. I feel the same way when I hear people speculating about how Bernie Sanders would have beat Trump in 2016.
i've spent the weekend binge watching the west wing and crying.
one of the recurring themes was this same tension between electability and remembering why these guys said they wanted to run.
on tv at least, when they tried to tack to the safe middle their approval ratings went down, and when they 'let bartlett be bartlett' (actually fight for food and health care and good education, the polls went up.
national politics is no longer carried out here in reality, so maybe a tv show has some wisdom for the dems.
Now that baby boomers have retired I'd say they're more likely to vote for benefits for themselves and not for everyone else. So I suspect any kind of universal health insurance proj will be a non starter for an easy decade if not longer.
After that as we learned from Obamacare. If it doesn't seem free to people. They'll never support it.
This means somehow magically the group healthcare benefits folks now have need to translate 1 to 1 over to the new system, and all the uncovered or partially so have to see no out of pocket new costs of just about any kind.
Exactly where we can hide all of it, no idea but there's plenty of to be thinking it through.
Steven’s loves Israel (that has free education & healthcare) more than the US. She’s told us this. Why would anyone expect her to help the people here, when she’s devoted to a foreign country?
Isn't that true for El-Sayed?
He seems to cater to people who care a lot about Palestine. This attitude pretty much helped elect Tr in 2024..
The people of Palestine are being ethnically cleansed and genocided. Caring for those that are suffering is merely the moral choice. Why would anyone choose to support evil?
The “ for all” is the MOST important part of Abdul's slogan. Sure Medicare if we get there, but policies dedicated for all our communities well being, and not toward hate and violence sponsored with our $ and legislation.
I have read from one independent media source, perhaps another writer on The Bulwark, that Medicare for All can’t be afforded. I don’t remember the details, but a good case is made for not being able to pay for Medicare for All. I don’t think much of anything in the way of new legislation that involves spending can be passed without rescinding the tax structure that effectively lowered taxes on the rich. Small changes in payroll taxes would go a long way toward securing both Social Security and Medicare. Tax policy is hard unless you have a Republican President like Trump who favors the rich for obvious reasons, and control of both branches of the legislature. Reforming tax policy that changes tax rates for the rich, taking away the bonus the Republicans (Trump) enacted may be hard to get past a Trump veto. Changes in the idea of Medicare for All have to be incremental. Whoever wins the nomination will be subject to vicious attack ads from the Republican Party candidate. I think El-Sayed is more vulnerable, but I live in Alabama, where we don’t have to concern ourselves about the direction of our state. Anyone with a D behind their name stands no chance. The D may as well stand for defeated.
I am a lifelong Democrat who has never voted for a Republican. I am a big fan of Medicare for seniors because, let's face it, most of us are essentially uninsurable once we hit 65. But in general, I do not think we should do things in the public sector that can be handled competently in the private sector (with of course guardrails in the form of appropriate regulation and antitrust enforcement). And so while I completely support the idea of universal health insurance as a matter of good policy, does that really require a Medicare for All approach? How's that been going for Great Britain?
At the time of the Obamacare debate, I read T.R. Reid's book, The Healing of America. Everyone should read that book. We need some honest and open debate about the relative advantages and disadvantages of the systems Reid sampled. I for one would put my money on Switzerland's approach. I think we need to let go of our attachment to the employer-based system of health care. Why should employed individuals have better options than the self-employed? Put everyone in the individual market, introduce real competition among insurers by drastically increasing their number, and let actual competition drive down rates. Take that burden off of our small businesses. Make the patient the actual customer of the insurance company, not his/her employer, which would enable plans tailored to the patient's needs and greatly enhance responsiveness to patient concerns.
“ Make the patient the actual customer of the insurance company, not his/her employer, which would enable plans tailored to the patient's needs”. - person young and healthy, takes no insurance; grows older and sick, now wants insurance - yes, this is tailored to the person’s needs but is also economically unsustainable.
Under the Swiss system, everyone -- including the young and healthy -- is required to buy insurance. An "individual mandate" if you will. So adverse selection is not a problem.
At one point during my working life, my employer decided to squeeze down the plan options so that employees were effectively coerced into a managed care plan (so, no PPO option). I had to self-insure my own primary care for a 5-year period, and use the employer plan as effectively "cat cover." I was fortunately able to get adequate coverage for my two children under the new plan. That episode really drove home the fact that I, as the patient, was not the customer. The employer was.
I was under the impression that the biggest opposition to Obama Care came from the mandate that you have to buy insurance.
Where my mind is at is that the free market (not really free as it is today, but that is for another day) can’t do many things well, and there is the idea of public goods. E.g., India decided that digital identity and digital payments are a public good, and so provided both. No Visa or Mastercard, but various apps built on a public Unified Payment Interface (UPI). These leads to the idea of a public digital infrastructure — the modern equivalent of the roads and highways.
The latest news is: According to Press Information Bureau, “Government of India has signed Memorandum of understanding (MoU)/ agreements with 23 countries for sharing or cooperation on India Stack / Digital Public Infrastructure (DPI).”
I don’t see why a basic standard of medical care cannot be a public good. Someone might be happy with the street their house is on being owned by a corporation because the free market is better as an ideological position. I would say, what works in real life often confounds ideology.
I guess we just disagree about the relative merits of free enterprise. I for one think it's a big part of what has made America such an extraordinary economic success.
In terms of the individual mandate, I believe it still exists, but the first Trump administration eliminated any penalty for noncompliance in 2017 in an effort to undermine Obamacare in the hopes that it would collapse of its own weight. But amazingly it didn't.
Young, healthy adults should not fool themselves that they won't end up paying just as much for a "Medicare for All" option, one way or another. At least under a Swiss model, they can tailor their coverage to suit their needs, with say, higher deductibles to keep premiums down. And we would want to keep those essential Obamacare features we tend to take for granted today, such as elimination of pre-existing conditions and lifetime benefit caps.
not if billionaires and corporations paid their fair share.
the context for all of this is this: in the last forty years 170 trillion dollars of wealth moved from the 90% to the epstein class.
more context: fifty years ago, mobil oil suppressed their own study which found that if they kept going as they were we would end up with the clmate disaster we have.
taxpayers paid for being screwed over with subsidies and tax breaks and other legal ways the rich found to keep from paying their fair share.(remember warren buffet said his secretary paid taxes at a higher rate than he did).
now their spending is enough to make it look like consumer spending hasn't fallen, while half the country has to decide between food for their kids or gas to get to work.
so, yeah, those folks watching their schools and hospitals tank might 'end up paying just as much for a "Medicare for All" option' ... but only because the billionaires have warped the system to make that happen.
Large employers are able to get health care for their employees at a discount.
Yes, indeed, the large employers have enormous bargaining power. And that is precisely the problem. Those discounts then get effectively subsidized by the individual market. We should not be creating two different classes of insureds, one favored and one not. And with more competition, everyone should be able to get the more favorable terms.
How many independent health care insurers are out there now - I believe the market has been consolidating. How would you bring back competition? How would you make it efficient for a physicians’ practice to deal with a hundred different insurance companies?
Good point about market consolidation. We do not have enough health insurance companies at the moment to populate a Swiss model. I believe it would take government intervention in the short term to incentivize more insurers to enter the market. Perhaps as part of an interim solution, the large insurers could be persuaded to offer a greater variety of plans while we transition to a more competitive carrier marketplace.
And you make an excellent point about doctors' offices having to cope with too many forms. I believe the Swiss had an answer for that, which Reid covered in his book, but out of laziness, I just googled the question, and came up with this answer: Swiss health insurers are required to use standardized billing structures and uniform data formats set by federal law. Key elements include uniform tariff codes, standardized electronic data formats, and identical basic benefit catalogs.
So standardization is key. You are absolutely correct.
The problem for a Swiss model is that, by default, health insurance (and the practice of medicine) is regulated by the states in the US. ERISA at the federal level is an exception, not the rule.
You'd run smack into federalism concerns in the courts.
Such a good point. I only know that the ACA imposed and has somehow managed to navigate a dual regulatory system of oversight for health insurers. The federal government was able to set pre-existing condition bans and minimum essential health benefit rules, for example, while the states have continued to approve plan rates & forms and conduct financial surveillance. So somehow the lawyers drafting the law managed to work that much out, and survive any court challenges. Getting the states to agree on claim forms would admittedly be a herculean task. This would need to be a joint initiative of the AMA and the NAIC, with input from local medical associations and insurance regulators.
Much of the inefficiency in the practice of medicine today is driven by the suffocatingly complex paperwork required by insurers. Fixing that problem would, in and of itself, drive real costs out of the system and improve patient care.
"Medicare for All—a proposed version of universal health care that would have the government cover everybody directly, mostly doing away with private health insurance"
A noble concept but with some inherent flaws that need to be addressed:
* Medicare pays out more than it takes in through premiums and dedicated taxes on payrolls. This is especially true for Parts B and D which is heavily subsidized via other taxes.
* Medicare Advantage (MA) is a scam for insurance companies to be more profitable. MA costs ~20% more than comparable standard Medicare and increases costs for Medicare beneficiaries:
> "The Medicare Payment Advisory Commission (MedPAC) estimates that, in 2025, payments from the federal government to Medicare Advantage plans exceed what spending would have been in traditional Medicare by 20%, which translates into $84 billion in additional spending. Higher payments to Medicare Advantage plans increase total Medicare spending, strain the Part A Hospital Insurance trust fund and drive-up Part B premiums for all Medicare beneficiaries. This raises questions about whether the current payment system provides strong financial returns to insurers at the expense of the federal budget, Medicare beneficiaries themselves, and U.S. taxpayers" https://www.kff.org/medicare/how-medicare-pays-medicare-advantage-plans-issues-and-policy-options/
* Will those of us, including my spouse and myself, who purchase supplemental insurance (not MA plans) through private carriers have the same coverage as Medicare for All?
* Misunderstandings of exactly what Medicare is need to be clarified, and with no political spin:
> "Politicians and many Americans frequently describe Medicare as if it were an investment account: Americans “pay into” the program with their payroll taxes throughout their working lives, and in exchange get benefits when they turn 65. However, this is a misconception for two reasons. First, Medicare is a transfer program from workers to retirees, with current benefits largely being funded by current tax receipts. Second, Medicare beneficiaries over the course of their lifetimes tend to receive more in benefits than they pay in both taxes and premiums." https://paragoninstitute.org/paragon-pic/medicare-enrollees-on-average-receive-far-more-in-benefits-than-they-pay-in-premiums-and-payroll-taxes/
* What doctors earn annually needs to be taken into consideration. It takes time and money to specialize but some specialties are a tad overpaid. Eight specialties have an average salary of over $500k, with one over $600k:
> "Orthopedic Surgery $611,000
Cardiology $575,000
Radiology $571,000
Plastic Surgery[1] $554,000
Anesthesiology $543,000
Urology $535,000
Gastroenterology $530,000
Otolaryngology (ENT) $508,000" https://medicalaid.org/blog/highest-paid-doctors-in-the-united-states/
([1] Plastic surgery is composed of two parts: reconstructive and cosmetic. Reconstructive is considered essential while cosmetic is... well... cosmetic. IOW cosmetic surgery is elective, reconstructive is not. IMO, it's the folk with a low body self-esteem seeking surgical enhancements that drive up the average salary.)
fnord
OK, but. The current system sucks. We pay far more for healthcare than anyone else in the world while getting 2nd tier results. This has been true for decades. No offense meant, but determining the details at this point should be secondary to moving the healthcare ball forward. A rainbow of opinions from Stevens to El-Sayed on how to get there is fine. If real healthcare reform is the goal, and our reps are not corrupted by PACs, the specifics will be worked out, tried, and adjusted. Things will get better. If we throw up our hands and say we cannot do what every other advanced nation does in one form or the other, they will not.
I'm not offended by a different POV, and the devil is in the already established details. I'm not arguing that the system is good, or even fair to middlin'. In fact I point out a couple specific places that it sucks, bigly, and are in critical need of correction: Medicare Advantage plans and doctors earning outrageous salaries.
Another thing that bites the big hairy meatball when it comes to medical costs are the ads for prescription drugs in all media*. There are only two countries that allow Big Pharma to advertise directly to the consumer:
> "The United States and New Zealand are the only countries that legally allow direct-to-consumer pharmaceutical advertising. (The European Union was furious when Lady Gaga’s Instagram post promoting the migraine drug was visible on the continent, noting it flagrantly violated its ban on direct-to-consumer advertising.)
Manufacturers have spent more than $1 billion a month on ads in recent years. Last year, three of the top five spenders on TV advertising were drug companies." https://jheor.org/post/2674-with-tv-drug-ads-what-you-see-is-not-necessarily-what-you-get
(* IDK about you but I'm more than sick [pun intended] and tired of hearing "ask your doctor if [the Rx] is right for you." This is especially galling when it comes to meds for a disease or illness that afflicts 1:1000, 1:10,000, and even 1:100,000.)
No matter that there are ads in NZ, med prices are subsidized:
> "People need to pay the standard $5 prescription charge, with exemptions for people:
◾ aged 13 years or under
◾ holding a Community Services Card (CSC), or a dependent child of a CSC holder
◾ aged 65 years or over
◾ holding a Prescription Subsidy Card (PSC)." https://www.healthnz.govt.nz/health-topics/tests-and-treatments/medicines/prescriptions
(Follow link for more deets, including the point where no co-pay is required at all.)
I agree with you that the healthcare ball must be moved forward with no moving the goalposts or Calvinball from the pols, but without some focus on the existing deets this is close to impossible.
fnord
Man do I appreciate Cohn's view of the political landscape. Maybe he has some biases that line up with my own or maybe it's just that he is able to articulate the big picture without bias, but when I read his stuff and hear him on podcasts I don't feel like his underlying message is, "progressives are just children who don't understand the only feasible way forward is to court centrists." It is possible that El-Sayed can't win in the general (though it's certainly possible that he can), but as the Republicans have shown, hammering home a point of view WILL eventually change the perspective of the electorate. There's no point in winning if we're just going to stay on the same political course that brought us MAGA.
Somehow healthcare for all doesn't strike me as a mantra MAGA would ever have.
Exactly Paul, very well said. The perfect congress would include some centrists with focus on rules and responsibility...but also dreamers with ideals that inspire new generations to join the fight and keep an eye on the prize. We would never have gotten ACA without dreamers like Bernie, forcing the centrists to remember why they were in congress in the 1st place. You do not have to agree with everything a representative says for them to be a valuable force moving the country forward.
Yeah, sure. Dreamers like Truman and Eisenhower. That’s how “radical “ this idea of government health care for all is.
No doubt, there's a role for dreamers and gadflies in Congress. However, it's usually a problem when they get access to actual power.
Such folks may help frame the debate, but take the ACA example you mentioned. You might credit Sanders with bringing it to the discussion, but who actually did the hard work and got 'er done?
And bear in mind we're talking about a "reasonable" topic here (health insurance) that reasonable folks can disagree about. Throw in some DSA types that are yapping about doing away with all police and prisons, and, well, let's just say (a) not a good strategy for winning elections, (b) stupid ideas!
Abdul is not saying anything that you are saying. Yapping is all centrists actually do and not in a good way.
I didn't say he did. Indeed, the whole point was that some of his fellow travelers say such things and it muddies the water for him. Let's suppose for the sake of discussion that Abdul is only interested in a (sensible) MFA program; that's his only focus. By associating with others that say they want to do away with the police, etc., it pulls him down, makes him less credible.
That said, it's not like the guy doesn't say some, uh, questionable stuff.
No matter who the nominee is all Democrats must unite behind them, this senate seat must stay Blue.