As the old saying goes: "when Democrats have a firing squad, it's always in a circle."
1
The credibility of those associated with your named think tank is under question. Supposedly the ACA was going to provide universal coverage, but it didn't, and in some ways our system is still getting worse and worse.
I'm sick of this garbage approach of creating plans that pussy foot around big insurance and big pharma. Enough!
Medicare for all. Bernie Sanders has the right idea. You fooled us one too many times.
7
Terrific column, thank you!
1
What about long term care? My wife has Parkinson’s Disease... don’t ask what you have coverage for after you retire! Zip, zilch, nothing...
Full time care at $10,000 per month! What world do you live in? Adult day care? $100 per day, $3,000 per months! No problem for the other spouse... just sell your house and all your possessions and hope to god you don’t outlive your savings!
Meanwhile Trump and the boys cut Medicare, Medicaid and promise something bigger and better...
What a joke!
13
Democrats have been claiming to support healthcare for all since 1945. Why would anyone believe them this time around?
https://emcphd.wordpress.com
3
A somewhat similar approach to the "Medicare for America" plan was proposed at https://aneconomicsense.org/2019/02/25/market-competition-as-a-path-to-making-medicare-available-for-all/.
The core of that proposed approach would be to allow market competition from Medicare-managed plans. For individuals, a Medicare-managed plan would be made available (at a breakeven cost) as a public option on the Obamacare market exchanges. And for employers, Medicare-managed plans would also be allowed to compete with private insurers for health plans for employees. Again, they would be priced to cover costs.
The key is for congress to allow such competition. If it did, one would expect many individuals as well as employers to choose such Medicare-managed plans, as Medicare is managed far more efficiently than private health insurers are in the US. The administrative expenses of private health insurers are five times (yes: five times) what they are for Medicare.
No one would be forced to enroll in the new Medicare-managed plans. But by being able to provide health insurance of better quality at lower cost, one would expect many will choose to make such a switch.
4
I just contributed to a go-fund me set up for someone who has insurance with high deductibles. This person has had a few medical issues resulting in a couple of surgeries. Add to that a serious eye condition that will require periodic injections to prevent blindness. Already there has been very serious eye loss in both eyes. If you can believe it the insurance company no longer wants to pay for the expensive injections. And as s result of the high deductibles bills are mounting.
This story is not an isolated situation. It’s infuriating that in the richest country in the world many people are denied vitally needed treatments. So let’s stop with this non-sensical debate and demand what every other advanced country (and POORER countries) do: provide comprehensive, cost-effective health coverage to everyone.
At least 30% of our healthcare dollars goes to insurance middlemen and administrative waste on the provider end due to a multi-payer system. According to a Reuters poll taken last August, 70 percent of Americans support Medicare for All.
Canadian Medicare: 100% coverage — no bills — no co-pays, no deductibles — no bankruptcies — no insurance bean counters to override doctors — better prevention — better health outcomes
Real Canadians Talking Real Healthcare
https://m.youtube.com/watch?feature=youtu.be&v=VQFX32Ed7ZQ
"We just go and and your taken care of, and everybody is treated the same. That's what a democratic society is, isn't it?"
11
"Britain has true socialized medicine — direct government provision of health care". That's not accurate, Dr. Krugman: 10.5% of Britons also have private health insurance, for which they pay extra. https://www.internations.org/go/moving-to-the-uk/healthcare/private-health-insurance-in-the-uk.
This has always existed, I have a 1960s British joke book about an obese man whose friend tells him about this wonderful weight-loss drug his doctor gives him: during sleep, he dreams that he's on a desert island chasing beautiful women, and on waking, he's sweated off some weight.
The man goes to this doctor, takes some pills, and finds that he loses weight through nightmares where cannibals chase him. The doctor, asked to explain, says: "Your friend's a private patient: YOU'RE on the National Health Service."
2
Agree that there is nothing inherently wrong with choice in health care insurance, as long as the system has appropriate safety nets that recognizes both that we have a responsibility to take care of sick and injured citizens and that in the real world, the system will try somehow to accommodate them. When someone is having a heart attack, insured or not, the system will usually respond; it's just a huge bill comes that either he/she can't pay or which leaves them destitute. The current system will try to save lives, but won't protect assets. Also competition does create some incentives to lower cost in the name of getting insurance "customers" by offering lowering insurance premiums. The savings, however, may go to investors, not into the system, which is not the best choice.
The idea that Medicare for all will solve the US health care problem unfortunately is largely fantasy -- get sick and everything gets paid for. Nice, but Medicare still has high coverage gaps, upward of $7500 for prescription meds (https://www.kiplinger.com/article/retirement/T039-C032-S014-medicare-part-d-costs-and-deductibles-for-2019.html) which still puts a lot of medical care out of reach in the real world of limited incomes.
The real problem in the US is the high cost of medical care, both from high insurance costs and high out of pocket costs, insured or not. This is from predatory pricing of medications and other inputs. Controlling these costs should be the focus of reform.
6
There are multiple ways to achieve universal coverage , but some are better than others.
For readers like to be informed I recommend
"A Better Path to Universal Health Care
The United States should look to Germany, not Canada, for the best model.
By Jamie Daw
Dr. Daw teaches health policy and management at Columbia University.
https://www.nytimes.com/2019/02/20/opinion/health-care-germany.html
and
Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55
https://www.nytimes.com/2019/03/21/opinion/diabetes-insulin-generics-humalog.html
Most importantly, any reform needs to break the strangle hold the insurance companies hold on health care
Under the ACA, their prepare profits 2009-2015, increased from $ 15 Billion, to $ 25 Billion, almost doubling in a mere 6 years. See for yourself
https://www.economist.com/sites/default/files/imagecache/640-width/images/print-edition/20151205_FNC666_0.png
The ACA gave the insurance industry what it wanted.
Time to end it
6
Something needs to change. But Prof Krugman should know well that grand social/fiscal change in a vacuum is doomed to fail. We must:
1. Make everyone pay taxes (ie get rid of the cash economy)
2. Make everyone capable work (ie get rid of the disability gravy train, give up the idea that there are jobs "no American will do." They will do them, if there is no payout to them without it.... people are as good as their best option).
3. Eliminate the illegal problem- you cannot bring your parents to this country an expect Medicaid (free medical care). You cannot jump a fence and come her.
4. Understand that you cannot have carte blanche like we have today in Medicare. 90 year olds cannot get life-sustaining ICU care without consideration of cost. You cannot have an MRI today, or maybe not at all if it is not truly needed. You don't get your shoulder fixed just so you can play golf.
Americans will need to learn the word "no" or the words "get in line." Check out:
https://www.hqontario.ca/System-Performance/utm_source=Ontario.ca&utm_medium=Referral&utm_campaign=WT%20Referral
This is the wait times in Ontario Canada for various things. It is "good" medical care... just not what Americans who currently pay for their care expect and demand.
3
Yes! Two things to add:
1) Remember, Obamacare is hanging by the thinnest of threads, and Obama's biggest error was to claim 'If you like your health care plan, you can keep it'. Medicare for all explicitly intends to take away your health care plan, whether you like it or not.
https://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/
2) "There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have." Getting there from here, Atul Gawande, New Yorker 2006 https://www.newyorker.com/magazine/2009/01/26/getting-there-from-here
Why I am alive in Australia:
The Federal Government will spend upwards of $200 million on making four new cancer drugs available on the Pharmaceutical Benefits Scheme (PBS).
‘From 1 March this year, patients will be able to access all of these medicines for just $40.30 per script, or $6.50 with a concession card.
https://www1.racgp.org.au/newsgp/clinical/four-‘breakthrough’-cancer-drugs-added-to-the-pbs
5
“But I could be wrong [about keeping private insurance]!”
Yes, Paul, you’re wrong. I contributed to a go-fund me for someone who has insurance with high deductibles. This person has had a few medical issues resulting in a couple of surgeries. Add to that a serious eye condition that will require injections to prevent blindness. Already there has been very serious eye loss in both eyes. If you can believe it the insurance company no longer wants to pay for the expensive injections. And as s result of the high deductibles bills are mounting.
This story is not an isolated situation. It’s infuriating that in the richest country in the world many people are denied vitally needed treatments. So let’s stop with this non-sensical debate and demand what every other advanced country (and POORER countries) do: provide comprehensive, cost-effective health coverage to everyone.
At least 30% of our healthcare dollars goes to insurance middlemen and administrative waste on the provider end due to a multi-payer system. A Reuters put shoes that 70% of Americans support Medicare for All.
Canadian Medicare: 100% coverage — no bills — no co-pays, no deductibles — no bankruptcies — no insurance bean counters to override doctors — better prevention — better health outcomes
Real Canadians Talking Real Healthcare
https://m.youtube.com/watch?feature=youtu.be&v=VQFX32Ed7ZQ
"We just go and and your taken care of, and everybody is treated the same. That's what a democratic society is, isn't it?"
2
Paul says: "the Netherlands actually tops the Commonwealth Fund rankings."
Nope. The UK does.
https://interactives.commonwealthfund.org/2017/july/mirror-mirror/
Why are Democrats even focused on healthcare? A mere ten years ago President Obama promised us a universal coverage utopia and Nancy Pelosi and Harry Reid enthusiastically delivered. Now, we have to suffer through a Democratic field of clueless candidates, most of whom were never employed outside of politics, try to outdo each other on introducing ever more radical plans to nationalize our healthcare. This radical overreach is occurring while Finland’s government collapsed under disputes over skyrocketing healthcare costs. https://www.wsj.com/articles/finlands-government-collapses-weeks-before-general-election-11552037078
Politicians are incapable of running sustainable long term welfare programs because their interest is always on the short term (i.e. re-election). Our skyrocketing debt is evidence that we should keep politicians away from our healthcare, and most everything else for that matter.
2
"What won’t be fine will be if activists make a no-private-insurance position a litmus test, declaring that anyone advocating a more incrementalist approach is no true progressive, or maybe a corrupt shill for the medical/industrial complex." Are you listening Bernie Sanders? Please absorb the wisdom here.
3
Private insurance is mostly there to say No, you can’t have that, but if you do, we’re not going to pay for it. And we currently pay through the nose for these companies to tell us that. Who in their right mind is “satisfied” w that? Only stupid people or people w ties to the health insurance industry. No, private health insurance, w the possible exception of “boutique” brands for the wealthy, should be abolished. I don’t often disagree w Mr. Krugman, but this time I do. Wholeheartedly. Is my view impractical? Let’s forget the polls and vote on it.
42
Finally some clarity on the MFA issue. I'm a family physician, and very much support universal, dignified, efficient access to high quality healthcare for all. For the US, Canadian Medicare (they call it that) would probably be most efficient, but given the politics and peoples beliefs about the govamint, a Swiss/German/French/Dutch style heavily regulared private insurance scheme with a public option is most likely to gain traction.
BTW, I am not Laura Bierema (my wife) I am Mark Ebell MD. Although she is super smart.
320
Mark Ebell,
People's beliefs about the govamint? Times are changing when it comes to our dysfunctional health care system. According to a Reuters poll taken last August, 70 percent of Americans support Medicare for all.
"... a Swiss/German/French/Dutch style heavily regulated private insurance scheme with a public option is most likely to gain traction."
Really? What are the chances of our bought-and-paid-for politicians "heavily regulating private insurance"? Obama said he favored a single-payer systems in the 2008 campaign. Not only did he drop that idea, he also dropped the public option once in office.
As Bernie Sanders says, change never takes place from the top down. It takes place from the bottom up.
36
@Laura Bierema
The critical issue is "heavily regulated" private insurance. How is that regulation working for aviation these days?
17
@RLS
Plenty of change takes place from the top down. We're watching a huge amount of it right now. But ... you know.
5
Exactly Sensible now please listen .
I really wish that the healthcare debate would focus on what it’s actually about: not health, and not care, but, simply, how it’s paid for.
Private health insurance companies don’t provide health care. All they do is front the money to the doctors and hospitals that actually do.
In the end, it doesn’t matter where the money comes from, as long as it’s there when someone needs medical care, and there’s no reason for the average person to doubt that the federal government will be there any less steadfastly than a private, for-profit company will (it is, of course and unsurprisingly, the private company that will always be looking for reasons not to authorize a course of treatment).
Senior citizens have no apparent qualms about the government’s commitment to pay them Social Security earch month, and to make timely Medicare reimbursements to their doctors, so why should an expanded Medicare for All, or “Medicare for America” be any different?
The problem is not with the workability of any of the universal health care plans Krugman outlines, but with their advocates’ inability to explain them properly. I have no doubt that if the correct were to be made, even the most skeptical member of the public would, at the end of the presentation, respond by saying “where do I sign up?” and/or “I can’t wait to vote for the politicians who promise to make this happen.”
5
Most advocates could not get in a room of patients and doctors and answer their questions honestly. Example Medicaid plans are implemented without education, feedback, or support
1
How could Medicare for all not be cheaper than our current system of health insurance? Years ago, William McGuire, CEO of United Health, a Dow 30 component, got caught illegally backdating options and compensating himself hundreds of millions of dollars. That money didn't come out of thin air but from excessive health insurance premiums which made UNH a very profitable investment, especially for McGuire. He should have gone to prison. The SEC slapped his hand and forced him to step down from his position. Now he owns a Major League Soccer franchise in Minnesota. We have a bloated investor-owned health insurance industry in America which drives up the cost of medicine and health insurance. Medicare for all is the best system.
7
There are a lot of ways to achieve the goal of universal coverage.
One thing we need to do is to reverse the idea that becoming a doctor is a guaranteed path to wealth. We have an artificial shortage of doctors in the U.S. There are many qualified applicants to medical school whose primary goal is to help people who cannot gain admission to medical school.
We should expand the number of medical schools, thus providing a larger supply of doctors. If we could figure out a way for someone who is not already wealthy to become an MD without racking up a huge debt, that would be a good thing as well.
7
For those who decry the democrats as not having a plan for healthcare they never seem to mention the republicans intransigence toward Obamacare. Obamacare has flaws but good faith bargaining could have improved it. Instead republicans said they would repeal and replace. Do you know what they would replace it with? Yep neither do I.
6
I'd like to add one,(okay two), more things that I feel should be covered under our medical plans; dental and vision care. Many of our health problems start in our mouths or are manifested there. And vision, if you can't see, it's really hard to contribute or, I just can't imagine what it would be like if my eyes were worse than they are. If we eliminated for profit insurance and left the non-profits I think that would solve many of the issues in this most contentious debate.
5
Liberals demonize the insurance companies, when the real culprit in health care costs is providers (I know several doctors who own $3 million homes, or multiple homes and German sports cars), all those wonderful medical diagnostic instruments we have, and the beautiful new clinics and hospitals. I have several near me. No insurance company has ever denied one claim from my family, and we have a very complicated medical history, with lots of claims. "Medicare for All" is old fashioned price controls. Currently, the way our medical system is constructed, providers lose money on Medicare patients. They make it up through higher reimbursements from private insurance. If everyone paid Medicare rates, half the doctors clinics and hospitals would be in bankruptcy within a year. Supply would contract and lead time for doctors and clinics would run way out, and voters would be very angry. That's what price controls do. Our senior citizens should be grateful that they don't pay the full cost for the top notch treatment they're getting. That's why it seems too good to be true. Because it is. If we're going to go full government controlled system, it will need to be done over a generation, with a complete revamp. A lot less clinics, and doctors and nurses will need to get used to making a lot less money. Taxes would also need to go up to European 50% levels. Good luck with that.
3
As I am eating dinner for 5 minutes while in the middle of seeing patients at6 on on a Friday and not able to hire someone with too much debt while I serve a half Medicaid population while government works 40 hrs a week and administrative doctors make 2-6 x as much working half the fours and failing to provide support. I am very grateful for my career and am not complaining about my income, just don’t tell me I’m the real problem. I can’t hire people even if I pay them what I make. Where are the primary care doctors going to come from to take care of he elder population? Or the children who increasing percentage live in poverty. The one certain way to drop medical care costs is to make people pay taxes on their insurance benefits and no government insurance. I don’t think anyone wants that but if you want better, less expensive care, support the doctor patient relationship. The docs along with nurses are really the best advocates for patients. One doctor got care in Germany where their visit required emr documentation which took moments. The American doctor asked how can you do that. The German doctor said”Simple- they trust us”. Without that no plan is worth their salt especially if you think three words are worth a trillion a year.
3
The idea of Single Payer/Medicare for All has been a part of Democratic Party policy discussions since about 1948. That was 70 years ago. Ted Kennedy was going to run for President on it in 1972. This is not a radical idea. As you say, every other developed country in the world has a version.
The problem with looking at the Swiss and Dutch public/private versions as a possible model for America is that we have about twice as many uninsured people in the US as Switzerland and the Netherlands have people.
Further, while polls may say that most people are happy with their employer supplied health care, employers are not necessarily happy with it and are always looking for ways to cut costs. And a lot times cut coverage. Talk to some of those happily employer covered citizens the next time their coverage gets cut—as it will, since health care costs continue to rise exponentially.
Having worked for the government, I'm not a big believer in big government programs, but in an era when Capitalism writ large has become a vast criminal enterprise, mostly aimed at gouging the consumer and squeezing the worker, sometimes, practically speaking, government programs are the least worst option.
Go talk to Robert Pollin about his analysis of the economics of Medicare of All and you can debate it on its merits if you want, rather than talking at the problem and messing around the edges. Pollin's version sure sounds doable to me. We want Medicare for All and we want it now.
3
Pollin’s argument depends on all the docs, hospitals, whatever, getting reimbursed at Medicare levels. Okay, fine.
So what happens when they say no, we won’t offer the same services at the same rates?
Another glaring prob: they claim they can chop costs by up to 40% overall, apparently because France is about 40% cheaper. But France’s system is a mixed system with a lot of private enterprise, a lot of weird stuff like reliance on pharmacists, and generally more-healthy diet, exercise and lifestyles.
Another prob: in all the OECDs, health as a percentage of GDP is climbing pretty rapidly, probably due to an aging pop. How do you make that go away?
2
@Wah
Sometimes you can’t have what you want. Become a doctor and treat yourself or offer your service for nearly free.
Krugman's proposal seems a lot like Medicare Advantage...a private-insurance alternative to regular Medicare, in which the government pays your premiums to an HMO or PPO for a plan that meets certain minimal requirements Like most American workers with health insurance, my employer offered several alternative health plans with varying restrictions, premiums, co-pays and deductibles. And, like most of my coworkers, I chose an HMO option that restricted me to a network associated with a major local hospital that had lower premiums than other options.
This has served me (and my family) well, even though we have had several major health issues among us. When it came time for me to retire, I went with a Medicare Advantage plan from the same hospital network which has provided me with virtually seamless coverage. This is all at no cost to me beyond the mandated Medicare Part B premiums...and includes drug coverage, basic eye exams, dental checkups and a gym membership! Of course, like my employer's plan (and like Medicare itself), it involves deductibles and co-pays.
A switch to a Medicare Advantage model would be nearly invisible to most workers. Like Medicare Advantage, more than one plan could be made available, some with lesser restrictions, but with additional monthly premiums. (Even old-fashioned, unrestricted Blue-Cross/Blue-Shield plans could be available, for a price)
For most, the only change would be the paycheck line that reflects the cost of the coverage.
3
The ballyhooed clichés of free markets & choice for healthcare got us to where we are today: premiums far outpacing inflation, huge deductibles, no pre-existing conditions, less coverage, pick & choose enrollees. Not to forget the rise of rent-seeking bill coders, pharmacy managers & pharmacies, & anyone else who wants a piece of the pie (which had to be made bigger to maintain profits). We’ve been there, done that, it hasn’t worked, except for the profiteers.
Steps toward MFA should be an interim solution on the way to single-payer (SP). Why SP? To keep it simple & because you shouldn’t need costly private Advantage plans which highlight the inadequacy of Medicare, & mainly because you can still go broke under Medicare.
Remember, US healthcare annual spending costs PER CAPITA (2016) were $9,892; UK 4,192; Canada 4,753; Germany 5,551; Norway 6,647. We also had poorer healthcare outcomes. By this measure these are the costs for everyone including those who do not have adequate, or any, insurance & whose costs are buried in higher premiums for the insured and in our local & state taxes.
Fund MFA/SP primarily via a modest increase in Medicare so all employees & employers pay & build the fund, it’s insurance after all. Gradually, employees & employers will decide whether to pay more for private insurance or opt to MFA/SP for the same care.
1
Democrats should change the language they use.
They should not refer to health care as a "right". That unnecessarily inflames the opposition, who hear it as "they're giving my money to Them".
Instead, Democrats should refer to health care as a responsibility each of us has to our neighbors. Republicans are more likely to bristle at "right" than "responsibility".
The fact is that everybody already has a form of health care coverage. It is in the Emergency Room. The ER can't turn anyone away.
But, not everybody pays for it.
And, there is a societal benefit in not turning them away.
So, to be fair to the people who do pay, everybody has a responsibility to acquire healthcare coverage. That justifies the individual mandate and the penalty for being uninsured.
There is still the issue of covering people who can't afford coverage. But, I don't hear even the right wing railing against Medicaid.
3
The TL;DR version of this is: "There are lots of ways to have universal health care. Medicare for All is a dumb hill to die on and will get Trump re-elected." For the sake of our nation and world I pray that in 2020 Democrats will appeal beyond a narrow base that is wildly disadvantaged by the Electoral College and Congressional gerrymandering.
2
suppose you have healthcare through your employer. if you have an issue, do you have to struggle to find someone who will accept it if? if you need surgery, will you find they've sneaked in someone out of plan to assist without warning you while you're etherized upon the table? what if your mother becomes too incapacitated to take care of herself, and you have to quit your job and move elsewhere to take care of her? who gets to be insured, mom on Medicaid or you, the sacrificial lamb? what happens when your job nd your insurance packs up and moves to Packistan, or you're forced to become parttime, or you need a new job but appear too medically costly at your age to be considered? the whole setup stinks like something from Dickens.
3
I don’t care what it’s called or what it is, but this : no profit is to be made from exploiting the need for medical care ! Medical care — when needed — is not an option, and one must pay whatever price is demanded ! It is evident that there is no medical care market. How a supposedly Christian country can impose the present medical care system on its people is a disgrace and an hypocrisy.
3
@Frank
What is wrong with earning a profit from meeting someone's basic needs? Do you begrudge farmers for making money feeding the hungry? Do you get mad about construction workers making money building homes for people? Are you made that clothing companies make money providing people with clothes?
1
Hypocrisy! Krugman starts by bemoaning the pundits' focus, not on the candidates and their proposals, but on their electability. Then goes on to contradict himself by proposing that, although it may not be the best healthcare system, we should try to enact that precise system because it is the system most likely to be electable. Apparently the difference is that, as to the individual candidates "... nobody has any idea what he or she is talking about.". Whereas, as it relates to healthcare systems, Krugman does? Thank you Prof. Savior! For my money I shoot for the best, no half-loafs for me.
3
A few numbers and facts.
1. Health insurances isn’t as profitable a business as often claimed. Its providers make between 1-7%, though of course this doesn’t change the fact that exec salaries are nuts.
2. The PPACA caps “overhead,” at 15-20%, and caps your out-of pocket costs at about 9% of annual income. Not great, not death.
3. An average family plan costs around a skosh below $19 grand a year. Without dental and vision. While there’s a ton of money to be squeezed out, it’s bonkers to claim you’re gonna finance MFA on squeezing 40% or so in “waste, fraud and abuse.”
4. The money’s in: a) costs of procedures, b) zooming drug costs, c) our poor general health, d) an aging pop, e) our demands for Everything Now.
5. We have a shortage of GPs, especially in rural areas, and it’s getting worse. MFA will not fix this.
6. The cost horrors are: mostly in the 55-64 age bracket; mostly in Red states.
7. No, European countries do not all have single payer. There are no simple single-payer systems anywhere. All systems limit what is available in some way. All systems require payment in some way.
8. Our health outcomes are generally mediocre. Our costs are ludicrous, and radically uneven.
9. More than half of us get insurance through an employer. They kick in around $14 grand a year, on average. If you think you’re ginna wave paper at these folks and get them to give that up, you’re nuts.
10. Universal and MFA are not synonyms.
Feel free to offer better numbers.
3
The key to switching from employer-based insurance to a Medicare-for-All plan is not trust in the government but trust in the employer! Does anyone trust that the money their employer is currently putting into your premiums will instead go toward your paycheck when a transition occurs? And what do we do with the fact that single people are getting different amounts of money put into insurance compared to employees with family plans. Will we see differential adjustments to paychecks? What if you are declining an insurance benefit because your spouse covers you. Do you get more money after the switch or nothing? It's already bad now because in some organizations, if you decline coverage you do not get extra pay. So the person in the office next to you may be getting paid $20k more than you because their employer is paying that much in premiums. After the switch will that same person still get more money?
2
From a personal standpoint I am watching this debate closely. Right now we have good coverage for which we pay a lot. The future is much less certain and frankly is very frightening as I have a daughter who has a serious chronic medical condition.
I would so like to see a reasoned and thought out product that covers all Americans but would definitely like to see the back of the insurance companies as I am not sure what purpose they serve other than to deny people healthcare whilst making themselves rich in the process. However, having worked in the NHS in the UK and having friends, both doctors, nurses and patients who deal with it everyday I have my concerns. But, having said that I think it has been seriously affected by Brexit and by being underfunded by successive Tory governments. Lots to consider folks but one thing is certain, anything the Democrats do will be way better them continuing with the ugly party that is in control right now.
1
I am firmly in the evolution camp versus the revolution camp in health care reform. To go all in Medicare for All is too drastic, and it will provide ample ammunition to the opponents. We should start offering a Medicare buy-in option, and make that policy benefit rich enough so people will want to take the buy-in option. And it should allow employees to take the buy-in option instead of employer provided insurance. Government should also provide tax and other incentives to companies so they favor the Medicare option over private insurance. In time, most people would have shifted to the Medicare option and private insurance can be phased out.
1
A Pew Research Poll dated January 24, 2019 states that the 2nd highest priority for Americans (after the economy) is reducing health care costs, with 69% agreeing. In 2011, the percent was 61%, so the trend is toward more dissatisfaction with these costs. This runs somewhat counter to Dr. Krugman's statement that "most of these people [with employer-provided health care] are fairly satisfied with their coverage."
https://www.people-press.org/2019/01/24/publics-2019-priorities-economy-health-care-education-and-security-all-near-top-of-list/
2
The medical/insurance "industrial complex" is powerful. Significant governmental changes to this "complex" won't happen unless they yield economic benefits to the "complex." Maybe some changes might occur if they are revenue-neutral to the complex. Those are lessons from Massachusetts' health insurance system and the ACA. (The Massachusetts health insurers and the medical business here are far from hurting as a result of "Romney Care.")
But any change that might take money away from insurance companies, hospital businesses, and/or M.D.'s is usually "D.O.A." Remember, there are still lots of folks, mostly Republicans, who did not support federal Medicaid and Medicare legislation in the 1960's, and still don't, because they still believe those federal programs are parts of "socialism."
There are times when one might believe that too many people in the U.S. are too stupid to deserve better then their status quo, so the country gets Trump and majorities in Congress who work to keep everyone in their places, the rich, the middle, and the poor.
1
Considering the lies they told to pass Obamacare- the Democrats have ZERO credibility on healthcare. (If you like your plan, you can keep it, the average family will see their premiums go down by $2,500)
Of course, for years the GOP promised to repeal Obamacare but chickened out, so they don't have any credibility on healthcare either.
4
Yeah, except that’s not really what got said. However many times the Right likes to cite Obama, because Hannity said to.
3
Medicare as a public option would be more than sufficient. If the party's position is to do away with private insurance mandatorily, then Trump will be re-elected.
You know, we older folks have seen this before-in 1972 on all issues and in 1984 primarily on the "...nuclear freeze..." opposed by all our NATO allies and supported only by the USSR.
We lost 49 states each time.
Bill Clinton had his faults but he is the guy who pulled the Party back into contention by triangulating.
Hopefully enough of the Young progressives and enough of the "...Old Hippies..." will respectively learn and remember.
Kamala harris has already shot herself in the foot on this very issue.
1
America a rich country. Tax wealth so everyone have all for free. Down down with rich.
1
Many of the comments I have read about this issue from other sources have scared the heck out of me. Basically rather than support the idea of some sort of Medicare for All, the comments ran to "you got that disease because you deserve by not eating correctly/not exercising right/ being lazy and undeserving". I was appalled at the meanness of those comments and I am very much afraid that there is no way to change the minds of people who think this way.
A moderate will just capitulate with republicans demands. The weakness of the DFL is that it has a whole lot of fake liberals called moderates or centrists. These people essentially neuter the party such that instead of healthcare we get the republican ACA. If the DFL is going to do what the GOP wants, we might as well all vote for Trump. What is the difference? We keep getting screwed by people who work only for the wealthy, and that includes many democrats.
I think is better to suffer a total collapse than to be constantly strung along with approaches that are insultingly ineffective and yet touted as solutions. The ACA is a prime example. It's just garbage and it was passed by democrats because democrat moderates wouldn't do anything real.
1
Paul Krugman is correct. The Democratic motto should be: "Medical Care for All". We can worry about the details when we have enough political power to make it happen.
2
I wonder if it matters that the population of the United States is so much larger than any of the other countries listed in the Commonwealth Fund report. The next closest is Germany with less than half the US (about 85 million vs. about 315 million). The Netherlands has fewer than 20 million. I have to believe this would affect administration of any government-provided health-care plan that would be taking over the current system. Add to that our Federal system, and I worry.
There is no reason not to try, but still.
1
Problems with the Dutch model (private insurance):
1. The goal of insurance companies is to make the largest legal profit. They will always attempt to keep costs down in the short run, and, importantly, in the long run they will never stop lobbying Congress and the President to allow them to make larger profits. Patient health always suffers.
2. The Dutch model is "heavily regulated, with lots of subsidies." Such a plan would, IMO, suffer a death by 1,000 cuts whenever Republicans take control. They would lessen the subsidies and deregulate in order for business to make more money. That is their playbook. On the other hand, a single payer system would quickly become very popular. Republicans might be afraid to attack it.
3
Back before Obamacare I used to half-jokingly suggest we put the names of all the wealthy countries that have one form or another of universal health coverage into a hat. Then draw a name and adopt that country's system. No matter what name was drawn, we would be vastly better better off. Even now, despite the significant improvements brought about by Obamacare, there are still tens of millions without access to affordable healthcare. Nice to see Krugman agrees with the essential idea behind my lotto plan, which is that achieving healthcare for all is the main objective. Yes, there are better or worse systems of universal healthcare, but all such systems are way better than not having universal coverage.
4
Insisting on "Medicare for all" vs. a system of universal care that allows people to keep their current employer--based plans plays right into the "Socialism" scare, and pretty much ensures a stinging electoral defeat.
3
I am a long time supporter of Single Payer. But Paul Krugman is right. Polls will show that people support health care reform. They support it right up to the moment they think it will change the health benefits they already have. Then they oppose it.
If the only plan on the table is Single Payer, everyone included, no other option allowed, it will lose in Congress. A public option in the ACA, allowing people to buy into Medicare, those are more likely to make it into law and to start helping people.
2
If your unfortunate enough to be admitted into a hospital, a hospital ostensibly in your provider network, the challenges lay ahead. For today's hospitals are labyrinths of billing codes and independent contractors. Contractors that are not necessarily in your provider network. A simple procedure may involve multiple such contractors and those contractors contract out to other contractors which provide billing that is more times than not unexplainable, erroneous and yes may even be fraudulent. At least that's been my experience. Then there's the calendar year deductibles that are financially debilitating, the co-pays, the in-network and out-of-network pharmacy and pharmaceuticals and last but not least the loathsomely expensive premiums. The current system is a nightmare wrapped in multiple layers of nightmares. Makes me want to get on my knees, pull out my samurai sword and slit my belly even as I type this.
5
of course, you're correct.
most important, i think, is to recognize that change in the provision of health care should occur in stages. the next stage for health care should be roughly equivalent to the provision of primary and secondary education: free public education for all who wish it (subsidized by school taxes); private education for those who choose it, with only minor subsidies.
the next "stage" should assure that all public health care is funded more than adequately, perhaps leaving private health care to boutique practitioners.
one thing too many "progressives" fail to recognize, apparently, is that today, more and more medical practices are being taken over by hospitals and/or other large coops or groups--and the bureaucratic "tyranny" and stupidity that emerges can be extremely frustrating. is "public" health care immune from the ills of overburdened, powerful bureaucracies?
Charles Gaba, continued...
"The up side, of course, is that around 300,000 more people would gain new coverage, while all 3.5 million would now be covered by Medicare.
"How much would this cost? Well, right now Medicare costs roughly $505 billion per year to cover around 54 million people, give or take. Some of these folks are covered due to disability not age, but let's assume roughly $9,400 per person per year.
"Now, it's safe to assume that 64 year olds will be less expensive on average than those 65 and up, and as you move down the age range the average cost should drop accordingly. For simplicity, however, let's call it an even $9,000 per person added under 65. That means adding 64-year olds would require an extra $31.5 billion more per year in the federal budget. This would also have an impact on other areas of the economy--the workforce (will some of these folks retire a year early?), risk pools...
"Give the entire system a year to adjust and recalculate everything...and then move on to the 63 year olds. Give that a year to adjust, move to 62 year olds and so on. If you're feeling particularly daring, perhaps do it 2 years at a time (but then give the system 2 years to adjust).
"In any event, after around 15 years, you'll have gradually shifted around 19% of the total population--everyone 50 and older, or roughly 60 million people using today's population--over to Medicare...all without destabilizing the rest of the industry."
http://acasignups.net/node/3085
3
Paul, Always insightful...I'm all forever whatever works...but I don't really hear anything from anyone about what's actually happening to the average American when it comes to Health Insurance. I've been a small business owner, employer, employee, ACA user... And lots of friends the same.
Here's what no-one seems to talk about.
No-one, on their own, if they are anywhere above poverty, essentially, afford healthcare. The ACA premium of rm in NY for a family of 4 is $30K. Yes, you heard that. $30K.
When I had healthcare through my employer, my monthly "contribution" was $850 a month for high deductible, kinda lousy insurance... that's $10,200 per year. Every single person I know who works for any size corporation faces the same expensive "payroll deduction". No matter how untaxed it is, it is still too expensive. Again, too much for a family that's not earning a decent, "middle class" living, and even then, it cuts into retirement savings, college savings... all the things we're supposed to be doing "right".
No one refers to this as an increase in the cost of living, but - boy howdy, it has been a huge increase (and money out of the economy) for me in the last 20 years.
All I hear about is lower prescription drugs. Won't do nuthin for me. Yeah, I'll save a few bucks, If I'm lucky - but we need the ability to be able to PAY for healthcare - no matter how it's delivered... taxes, private, it doesn't matter. Everyone must be able to get insurance. and I mean PERIOD!
3
@bailey.beeken
Dear Bailey:
Your use of monthly and annual premiums is right on the money. If you don't mind here is a market perspective.
Without knowing larger market prices, none of us is in a position to judge the appropriate cost of anything.
Here is a breakdown of a sample company.
For many years I represented corporate buyers of health insurance.
The unit of measure we used to compare plans was the PM/PM per member[person] per month.
In 2013, a major client, with 9767 lives and eleven health plans had a premium spread from $311.00 per person per month to $739.00!
The average per member per month , across all plans, was $369.45.
The final premium was $46,464,953.00
For a family of four, the lowest plan would amount to $14,928 per year.
The per member per month for most expensive plan, at $739.78, would have gross annual premiums of $35,509.44.
The is a difference of roughly 238%.
Again, this was six years ago.
Your $30,000 for a family of four, amounts, six years later, to a monthly per person per month premium of $625. That is still $114.78 per person per month lower than the most expensive plan six years ago.
I am retired so I don’t know what the current price spreads are.
Your premium is lot, but in the larger historical market, it is not.
Yep, here we go. This was inevitable: the "I like Medicare for all but . . ." from the moribund Clinton corporate Dems. Let's just redo 2016 since that worked out so well.
1
As long as there is a profit factor, it will always take precedence over the care part, which is why we have millions without health care, and those that do have it will always be subject to profit priority over their care. No mystery about what the problem is.
2
The Democrats need to stand up and point out that the benefits of the Affordable Care Act were blunted by Republican efforts to destroy Obama. Let's not forget that the ACA is largely a Republican plan with Democrat input. It should be revived and the recognized problems fixed.
Also the Democrats must continue to point out that every Republican plan proposed will have the effect of causing the death of thousands of men, women and children every year by denying them access to care. People with pre-existing conditions are toast in all of the Repub plans either by increasing their death rate or destroying them financially.
3
We need to listen and be open to compromise. But candidates need to be open to constructive criticism. I want to hear candidates speaking with the vision of Robert F. Kennedy, "I dream of things that never were and ask "Why not?". I'm far from being ready to compromise with old-school (it's safe) thinkers like Biden and Hillary, and even Beto. AOC appears to be one of the few who is willing to think about the future and she's not running for president.
2
If the US federal government remains the instrument promoting the welfare of the rich and big corporations -- the governance we have had under both Democrats and Republicans for the last 26 years -- then anything less than Bernie Sanders' Medicare for All won't work.
The powers-that-be, the rich and big corporations, will figure out how to funnel more and more taxpayer money at private insurances in order to "improve" them. That's exactly what the "improvements" to Obamacare and current Medicare do. (Consider the supposed "improvements" that Medicare Advantage plans bring, with their restrictive networks and yearly need to chase the "best" plan. And Medicare Advantage costs the taxpayer 10% more than traditional Medicare. Those aren't improvements.)
Private plans can play a major role in European health insurance because, first of all, the governances in those countries see their responsibilities to be the well being of all its citizens, not a small group of the wealthy. Consequently, their governance of private health plans is considerably more restrictive -- more socialistic -- than any American corporation would accept.
If we give private insurances an "inch" of playing room in US health insurance, they'll turn that into an ever-growing "mile" to "improve" the system at taxpayers' expense. The only thing improved will be private health insurances' income.
5
Litmus test, Bad. Got it, Dr. Krugman. Employer-based healthcare is, first of all, not a setup that most people are "fairly satisfied with as all that. I've looked at the study on which this statement is based...There are all sorts of qualifiers and caveats to it. Many respondents were not happy with this "benefit system." Employer-provided health "benefits" bind employees to their employers in ways that are restrictive. The Insurance industry still has a stranglehold over these policies that only offer limited in-network coverage, tight restrictions on what's covered, etc. etc.
Employer-based care also means that jobs are likely to be handed out to youthful, generally healthy people (ageism in hiring is rampant) in an effort by companies and insurance networks to keep costs low. Also, employees can be lured by decent coverage, that is later downgraded once they're employed (again, due to corporate desire to keep their costs low).
Finally, employer-based healthcare means that great numbers of citizens fall through the cracks - all the freelancers out there, for instance -- not to mention the unemployed, or the part-time employed.
4
The real problem with "healthcare for all" is that most of the under 30 year-olds feel they will never be sick, so are against mandatory health insurance. Without them, any universal system will fail. The US has aathree-fold system of Medicare/aid, private/employer funded, and self insured. This will be extremely difficult to change, since one or two of these three will feel they are cheated out of something. I cannot solve this, but I am curious as to what scheme the candidates will propose. We already know the Trump/GOP scheme which is "don't ever get sick or old".
1
There is no Constitutional sanction for ANY federally run medical plan, however virtuous, and Obamacare should have been nullified on Fifth and Tenth Amendment grounds.
Circumventing and ignoring Constitutional strictures eventually will lead us down a very dangerous path.
Those who wish to expand the role of the federal government in the areas of social insurance and social welfare should pursue this via Constitutional Amendment, not try to do this on the cheap.
1
A big problem with transitioning to a workable system is the T-word: taxes. In California in the 00's, the Lewin Group, very mainstream consultants, found that a proposal to provide single-payer healthcare relying most heavily on payroll taxes (8% employer, 4% employee, with a bottom-end exemption) saved just about everyone money and provided much more comprehensive healthcare. But it was characterized as "the biggest tax increase in history" by opponents, rather than the reality that it was an efficient re-direction of current payments made by employers and individuals, as Bernie Sanders often points out.
I worked on this proposal, and some on the left didn't like the use of a (somewhat progressive) payroll tax, even though it's how we fund our most successful social institutions-- social security and Medicare. So there's the need for a big reality check for Dems: yes, people will have to pay taxes to make this work, and no, taxes on the rich will not be nearly sufficient to finance it.
So not only is a transitional strategy needed, politically and operationally, of which Obamacare has been a first step. But the discussion has to grapple with hard numbers: who will pay and by what means? It could be a VAT, it's likely to be payroll, but Krugman is right: let the discussion begin, and don't avoid the financing.
5
@Lennyg
From where I sit, the increase I pay in taxes is FAR LESS than what the average American pays to the insurance company in premiums and EVERYONE is covered. In America, currently, with all the deductibles, at least 32 MILLION Americans are under-insured, have little or no coverage and 45, 000 die every year because they have no coverage at all! The largest number of bankruptcies in America occur because of non-payment of medical bills. This is insane!
Which way would you rather have it?
6
@Deus Absolutely agree. A tax-based system is far better and cheaper. The problem is how to get there in a country with a virulent anti-tax mentality. We pay far more in deductibles, co-pays, and insurance payments than we would in a tax-based system, proven by the Lewin study I cite.
1
The average family plan—no dental, no vision, just medical—costs around $19 grand a year right now.
Even assuming that you can chop that by a third, and that’s a big assumption, you’re still talking at least $13 grand, plus dental and cision which are cheapish but will still be another couple grand.
Okay, employer taxes cover two thirds of that: fine. You’ve still got a family needing to kick in five grand a year.
Median family income is about $55 K. On what planet is 4% of that five grand?
I say, bring on the public option - allow individuals (and employers, sure) to buy into Medicare with appropriate subsidies. But give everyone the option of buying in, even if we have employer-provided insurance already - let us choose the stable public plan and avoid having to change our insurance coverage every time we change jobs (or every time my employer decides to switch providers - i've had 3 different insurance plans in 9 years with the same employer!)
I'd love to get to a true single-payer system, but I think that the public option hybrid is the next step we should go to. If it works well, great! If not, tweak it! But what we have now is unsupportable.
4
Instantaneous change to a new system would be a massive disruption of our economy. I would support a gradual changeover starting at BOTH ENDS OF THE AGE SPECTRUM.
In the first year of "Buy-In Medicare" a 64 year old would be allowed (not forced) to BUY a "Medicare" policy instead of buying private insurance. In the second year a 63 year old would be allowed (not forced) to BUY a "Medicare" policy. Each year the age of eligibility would decrease. Adding 60-somethings who Buy-In does not cause an increase in taxes.
I would add pregnant women and newborn babies into a new Healthcare-for-Life division of Medicare supported by an Increase in Taxes on all income, including capital gains and dividends. The newborn would continue in Healthcare-for-Life until adulthood. At that point they could Buy-In or shift to private insurance.
1
The vast majority of those 156 million who are fairly satisfied with the health insurance that they get through their employers are probably saying so because they know no better. After having used health care systems in countries like the UK, Spain, France, Sweden and Canada, where I lived at different stages in my life, the coverage that, as a senior cryptography engineer for a big corporation, I receive through my employer is significantly more expensive, and in no way better, than what I used to get in each of those countries. The same was true of two other companies I worked for in the USA. When you don't know any better, feeling satisfied with what you got is a sensible strategy - if you can't be with the one you love, you'd better learn to love who you are with.
5
@IJK
The problem is as in ALL cases of employee based insurance, what happens when the job "goes away" OR one wishes to change jobs to what seems a better opportunity, yet, the potential new employer has poorer healthcare coverage then the company one decided to leave(especially important if one has a family)? This situation ultimately, inhibits the employee of progression and potentially the economy.
Citizens of other countries with universal healthcare NEVER have to face that potential "life changing" issue.
4
Transitioning to a single-payer system will be impossible with the GOP in opposition to it, given that they now control the Presidency, the Senate, and the Supreme Court. And of course the neoliberal wing of the Democrats don't like it either.
We are left to talk about how it could work. And two comments about that.
(1) Any single-payer system can be a failure if it is deliberately underfunded and mismanaged. We've seen that with the problems in the VA system.
(2) If a single-payer system were rolled out, allowing anyone to stay with their employer without penalty, I think we can see what would happen. Employers would quickly stop coverage and push employees (except top execs) into the public system. So much for employer choice.
The way to phase out employer-based health insurance is to make it more expensive for employers to provide it, so there is a greater competitive disadvantage as against employers who do not provide it. Right now the cost of providing health care insurance nudges employers to replace lower-level employees with part-timers or outsource their jobs to subcontractors who will not offer health insurance. In these ways, employers themselves are phasing out providing health insurance for some of their workers while keeping it to attract their full-time, permanent staff, who expect "free" health insurance as part of their employment. If some of these people start preferring to shop for their own health insurance, this will start a collapse of the employer-based system which would be welcomed by most employers. Many of them outsource not only the insurance itself but also the employee-insurer interface, so that coverage levels and problems are negotiated with and handled by a third party.
The upshot of how we provide health insurance is that we produce a stratification in the labor market, with an upper level that has health and other benefits and a lower level that lacks both benefits and often job security. Other countries such as Japan and France have the same stratification problem, but their lower strata have much better access to health care. Our history of racism has made us comfortable with such stratification.
2
It's such a useful purity test though. You can tell a lot about how much a candidate will or will not stand up to other entrenched interests by looking at whether they're willing to take the plunge and endorse wiping out the private health insurance industry. That doesn't mean no compromise is acceptable, but if Medicare for All isn't at least a candidate's first choice that's an easy way to remove them from consideration.
2
@Jake
The choice is easy, if a politician/candidate is NOT in favor of some form of universal healthcare, there is more than likely a healthcare industry "contribution" on their campaign donors list. Unfortunately, in the case of the democrats, three of the senior members of the establishment on that list are House Leader, Nancy Pelosi, Diane Feinstein and Senate Minority Leader, Chuck Schumer. NONE of these three support universal healthcare.
1
The ‘inconvenient’ reality is that demand for healthcare always, everywhere exceeds the available resources. The result is that care is rationed either by limiting access via government fiat (long waiting times) or by price (ability to pay) or some combination. Hence the lesser or greater role of private insurance. To determine the best fit for us, it might make sense to look not only at the UK and Holland but also the Swiss system.
1
My spouse and I are in our late fifties. We are beyond burned out from 35+ years each in our 9-5 jobs. We would like to retire and start a part-time home based business. We have worked and saved all of our lives and paid off our home. The only obstacle we see is healthcare. It doesn't need to be free, but it does need to be affordable and ideally somewhat predictable. I see the Medicare for All or nothing argument going on for a decade or more, whereas Medicare for America or some form of public option on the exchanges could start helping people much sooner. The public option, Medicare buy-in, whatever you call it polls very well. Let's be the party that works towards solutions that can be achieved.
4
US media is so addicted to prescription drug advertising that it will likely impede reform to keep the revenue flowing.
6
@Steve Bolger
Absolutely and that, along with the lobbyists, is why Americans have been haggling about healthcare(without any real resolution) since Harry Truman was President. The healthcare industry has now taken over the "distinguished" position as NUMBER ONE in the ranking of the amount of money spent in lobbying politicians in Washington, all done, to maintain the "status quo", the insurance companies profits and the CEO's bonus package.
Forget about Krugman and other establishment types who for decades now keep writing columns like this that continue to "muddy the waters"(are not in favor of single payer anyway) by saying there are multiple ways to do this which ultimately, just further confuses the voter on the issue and nothing ever gets done.
If America wants to at least, once and for all, join the current century in healthcare, start by electing those(not beholden to their corporate donors) that will actually do something about it.
2
Over a period of nearly three decades I have taught in Spanish universities several times and have been the beneficiary of their system of fully socialized medical care. Over the years Spanish friends and friends of friends have asked me a simple question: "How can Americans put up with their system? Doesn´t it drive them crazy?" My standard answer is that they can´t put up with their system and, yes, I does drive them both crazy and bankrupt.
In consequence, for the last ten years, ever since Obama sent the ACA to Congress, I have been making the exact same argument that Paul Krugman makes in today´s column. There is broad agreement regarding the objective among liberals and progressives of every stripe--universal or near universal coverage. There are many roads to that objective, and all of them involve arguments regarding the benefits of the various systems. And those arguments must be made in good faith, especially when they are addressed to people who are convinced that something nefarious is afoot. Until we reach something that looks like a consensus we will not achieve our goal.
2
Charles Gaba, excerpt on converting to Bernie's Medicare-for-All:
"How many regulations will have to be re-written? How many contracts rendered null and void? How many lawsuits would be filed over breach of contract?
"So far it doesn't sound like I'm a single payer advocate after all, right? Wrong. I'm all for it...but it's going to take years, possibly decades, to get to even in the best of circumstances. Here's how I could see doing it:
"The initial steps would begin with Medicare. Instead of raising the entry age from 65 (as some politicians have suggested in the past), I'd start to lower it...but very gradually. As in, one year per year, no more than that. 64...63...62 and so on.
"Why so slowly? Well, the total current U.S. population stands at roughly 322 million people. As of 2014, around 1.09% of those 322 million were 64 years old, or 3.5 million. Another 1.12% were 63 last year, or 3.6 million and so on.
"Moving 3.5 million people over to Medicare from their current coverage all at once may not sound that bad. However, these 3.5 million would be transferred over from a variety of existing forms of coverage. Again, look at the 11 categories; some would be drawn from each of these types of insurance (or from none at all). Not only would this cause some amount of disruption for the people themselves, it would also cause financial and legal headaches which would have to be sorted out for insurance carriers, corporations and so on."
http://acasignups.net/node/3085
2
"Medicare for America," with its insistence that insurance companies thrive before anything else, is not much different from Obamacare. That program, after it was gutted by the GOP in Congress, was actually a guaranteed income for medical insurers. It had little to do with medical benefits for US citizens.
In his essay, Krugman supports the unreasoning fear that Republicans have for government programs that actually benefit human beings. Republicans have no fear of social programs that limit freedoms and encourage the concentration of wealth.
What Krugman refers to as "a purity test" is actually the only solution to the problem. And - interestingly enough - he presents it as something that may increase "electability" - you know, that "silly stuff" he condemns in his first paragraph?
3
Can we add that Medicare & it's private sector "advantage" plans do not make for universal affordability? There are still $250 co-pays. There are still large "patient resposibilities". Medicare -for-all or any other major reform must solve the runaway healthcare cost structure we are saddled with.
3
@Bob Yes, and the Medicare Advantage Plans, run by private insurance companies, are NOT paying the medical claims so they can make more money now!
4
My employer spends 10% of my gross income on my health insurance alone. It's a hidden tax. It should be called out for what it is.
No other competent country has healthcare as its number one political issue. Adequate and good healthcare is available to people in other countries because the governments (like Netherlands, Australia and UK) have a huge stake in providing for their respective populations. Predatory profit motive in the medical sector is mitigated.
Healthcare should not be a partisan, political issue. It is a human issue that deserves high levels of empathy and compassion, exactly the abilities that the current version of right-wing quacks lack. Outlaw lobbying and revoke Citizens United. And then, acquire some humility and perspective and learn how Netherlands does it or how Australia does it.
Right now, this country doesn't have time for pols who prevaricate and twiddle their thumbs. Inaction shouldn't be tolerated. Show us the results.
3
Thank you for this discussion; you are correct.
Some seniors making comments here state how they love Medicare. That means they have not had a long hospital stay. You can go bankrupt fast if you are on medicare and have a long stay. Here are the payments for that copied from the Medicare site:
"Your costs in Original Medicare:
$1,364 deductible for each benefit period .
Days 1–60: $0 coinsurance for each benefit period.
Days 61–90: $341 coinsurance per day of each benefit period.
Days 91 and beyond: $682 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).
Beyond lifetime reserve days : all costs."
So you see you can soon be paying large sums PER DAY for a long illness. We do not want that kind of medicare FOR ALL. We want something better.
There are plenty of countries with many different plans that will work better. You are correct that we have to start the disscusion.
3
@Frank Where Medicare ends Medicaid kicks in. It--like all of American health coverage--is complicated and hard to understand so it can be vastly improved, but it's there.
4
@OrchardWriting
But you only become eligible for Medicaid after you've spent down all your assets. So even if Medicaid covers the rest of your stay, you're still dead broke for the rest of your life if you recover.
Review the public option in OBAMA CARE. Give people that choice. It might work well toward medical care for all Americans in the long run without major disruption to employer based insurance.
3
Healthcare is not a right, never has been, never will be. And it will never be free, someone has to pay for it. I will pay for mine thank you, but not yours. Cheers!
2
@Southern Boy If you have health insurance you pay for yourself and anyone who gets sick. That's how health insurance works and how a national plan would work. And a national plan--Medicare for America--is far, far better than what we have now which is the worst system in the industrialized world.
But I agree, labeling it free is extremely dishonest.
Hate to break this, dudes, but all insurance depends on getting as many as possible to chip in so that all are protected. If they aren’t, you get two choices: let ‘em die and watch your society crumble, or figure out simething else.
It’s all for one, and one for all, dude. An injury to one is an injury to all.
The Right’s prob is simple: it thinks it built it itself. Truth is, others chipped in in everything you have, and you could not possibly live like the rugged individualist you’re fantasizing about. Not in the past, not now, not ever.
Or to auite some guy named Heinlein: “the complete interdependence of modern life seemed to have escaped him entirely.”
@Southern Boy
Exactly
When you say "almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage." you neglect to mention that the costs are hidden from the employee, how satisfied would people be if they had the choice of taking the value of that plan as take-home pay? I had "great" insurance through a previous employer, but it was 1.5x more expensive than the best plan on the exchange, with a $1,000 greater deductible. People are afraid of losing insurance, of changing doctors. I'm not aware of any country with universal care that prevents private insurance, if people think that they're getting a good value they should be able to pay for whatever insurance they want. Single Payer, nationalized healthcare, mixed systems - none of these "take away your plan." This is propaganda. It is not "purism" to demand that our elected leaders do their jobs and reign in costs and provide the high-quality medicines and services to all Americans that our tax dollars ALREADY pay for. It is not "purism" to demand that corporations that fleece people with type 1 diabetes to pay thousands a month to survive, when the actual costs of insulin are $3 to $6 a vial and the long term costs of healthcare depend on timely access to sufficient medication. This isn't some stupid political debate - these are our lives and livelihoods.
2
The tax dollars of US citizens have been funneled to insurance companies for our healthcare. If you can't afford insurance, and even if you can your coverage could be denied and you could go bankrupt.
These corrupt companies do not deserve a seat at the table in our conversation about healthcare.
You bet it's a litmus test. Our tax money is funding unconstitutional wars right now. We pay as much as the next 12 countries combined on our military.
America is an oligarchy controlled by corporations and the wealthy and we want it back.
Medicare for All is indeed the litmus test. Any candidate that doesn't support it will be marginalized into obscurity.
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@Wbrink And thus, you identify as part of the problem, not the solution.
Employer health plans that used to be good are now raising deductibles to the point that most routine healthcare is out of pocket, so my friend winds up paying $600 per month for coverage and also pays out of pocket for almost everything. The only perk she has is not paying the up-charge of three or four times that an uninsured person pays.
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@bookcats
Routine healthcare should be out of pocket expense. What is wrong with that?
@Driven
Since you asked ... it's a puzzlement!
Without knowing premiums and the proportion of:
gross premiums to employee contributions: the net average out of pocket to copays to the actual medical charges:the relation of premiums to carrier rebates I don't think I could say.
Can anyone help me here?
Letting people keep employer sponsored healthcare but also allowing an option for Medicare makes sense. Once people realize that their friends and relatives who have switched to Medicare like it, they will be more likely also to switch. In due course, demand for private insurance will so diminish that new legislation establishing true Medicare for all will be enacted.
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We don't have to socialize the delivery process. What we do need to do is to socialize the cost.
That's where the Medicare comes into play. Provide a basic product that meets the needs. Levy a tax to pay for the cost. People that are employed can opt to use the basic system offered by government or choose from options provided by their employer. The government would subsidize the employer for the cost of the basic program, with enhancements to the program borne by the employer and/or employee.
Not to different from Medicare, where the basic is a flat rate often paid by Social Security, and the supplement programs and it's cost are decisions made and paid for by the individual.
2
The appeal of Medicare for All is that it doesn't allow for the death of a thousand cuts that Republicans will attempt to inflict on any hybrid system. "For all" doesn't allow for any exclusions on the margins. We've seen with Obamacare that there's nothing the Republicans won't attempt in an effort to discredit the system. Simple can be very good. Let's give the American people something good.
1
An incremental approach seems the most likely doable politically. As a senior on Medicare I have to say the transition to Medicare was seamless and i have never heard another Medicare recipient complain that they would rather be back on private insurance.
2
Readers need to understand that for most middle and certainly upper middle class Americans , the transition form private employer provided insurance to Medicare is not without its challenges . Primary care access remains a huge problem, even more so. Medicare reimbursement is simply no attractive to primary care physicians. Payments are simple, though. And with a medigap policy , pretty much capped. But if you need a brand or specialty drug, let alone orphan drug /biological to fight cancer, its a disaster. Overall, you certainly can expect to pay somewhat more out of pocket when you lose tax subsidized employer provided health care , especially when now BOTH spouses need separate policies. Overall access for specialists is a function of where you live. In major metro areas with many tertiary acre teaching hospitals access to specialists is excellent under Medicare, less so in rural areas.
1
In my country we have free government provision of health care. The quality of care is good, but waiting lists are long and people can't choose their doctor. In addition to this, public servants like myself pay 3.5% of their salaries towards a government-provided insurance system. This allows us to choose our doctor or a private hospital, in which case we are expected to pay part of the bill.
There is discussion of spreading this system to the whole population, but there is a problem with late arrivals; 3.5% of my salary covers costs because I have been paying since I was twenty-something and in good health. If someone from the private sector wanted to join this subsystem at a later age, they would have to pay an entrance fee which would be higher the older they were.
As I said before, this subsystem allows me to choose my doctor or hospital, but doesn't cover the totality of my expenses. So I have private insurance through my Teachers' Union, which covers most of my remaining out-of-pocket expenses.
This is just to say that the various solutions are not mutually exclusive, and can complement one another. A candidate that manages to show Americans that any new coverage they get will be on top of what they already have, and nobody is going to take anything from them, and that the different parts of the system will be articulated in such a way that it can't be gamed (nobody will profit from being ill) might get a lot of support from voters.
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Prof. Krugman raises a valid point. People in stable jobs who are currently covered at work fear change. But in a mixed system where some are covered by private insurance and some by a government program, private insurers will lobby the government to reduce benefits and raise premiums on the public option to guarantee their continued profitability, thereby undermining the public program.
2
Bloomberg recently ranked us 54th out of 56 countries for healthcare efficiency. We could do so much better by looking at what other countries like Australia or Spain have done. You only have to watch New Zealand right now to see the difference between a Democracy that cares about its people, versus a Lobbyocracy that cares about its 0.1%.
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Krugman mis-stated one important point: Beto O’Rourke has not only publically endorsed Medicare For America, but over the past week since announcing his candidacy, he’s elaborated in detail why he favors this approach during a number of townhall meetings. Krugman’s reasoning in this piece is also why Beto favors the Medicare For America proposal.
1
Here's the thing. I'm an old man now. I've been waiting, voting Democratic all my adult, waiting for Americans to wise up. Instead, the Democrats always going middle of the road, we have gotten ever more mired in the Molasses Sea of capitalistic republicanism. Democratic bandaids have only prolonged the agony and contributed to the ongoing, increasing inequality.
I'm tired and I don't much care anymore. If the Democrats can't offer us a REAL alternative to this ongoing capitalistic republicanism then I AM NOT VOTING FOR THEM ANYMORE.
LET THE GOP WIN AGAIN. LET THE U.S. GO TO HADES. IF THE DEMOCRATS DON'T GET THE REPUBLICANS OUT OF THEIR PARTY.
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I’m sure Trump thanks you.
I applaud the Funds efforts, but some of its methodology is suspect and politicized , even if only inadvertently. To rank France for example so low in access, administrative efficiency is absurd. Having used that system myself as an expat, as well as AU, CAN ,NZ and UK, it is extremely streamlined and simple both in enrollment and access for the patient. Now the bureaucracy and number of people employed in that bureaucracy, but that doesn’t impact patient facing aspects. With carte in hand, it’s as simple as charging a purchase at any merchant in the US on a VISA,MC etc. And its out of pockets costs are easily comparable with UK and CAN, and far less than AU. AU has a hydros somewhat complex system that while not as problematic or fragmented as the US, palpably more complex than UK,CAN or France, and many people must have private supplemental insurance policies as well, and in terms of equity and access, far closer tot he two tiered system we have in the US. The Dutch system IS very cost effective (we are talking about the Netherlands after all!) Access to specialty care is much more straightforward in France than UK, CAN or NZ. Overall, as a user, I would rank these systems FR>CAN>AU>NZ>UK. UK faculties are awful and terribly understaffed.Primary care is good, but overall most AMericans woudl never trade what they have for NHS. ANd most woudl not tolerate the waits for elective surgeries or specialty referrals that exhaust in NZ,CAN systems. France offers the best balance
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Au contraire, do!
Most Americans, be they on the left or right, now consider healthcare a human right. Thanks, Senator Sanders!
The road to regaining our self-respect as a nation includes the insistence from our candidates and elected officials alike to finally treat us and our nation with the respect we deserve. The American middle and working classes, after the battering of the Great Recession and now the Trump economy, are finally seeing that what they have "over there" in Europe, first of all, is a much better sense of national and personal self-worth.
Medicare for all takes the same money we hand over to Blue Cross, who earned billions and paid zero in taxes last year, for the privilege of being turned down when needing care, and paying blood ransom for it.
Enough is enough!
Beto doesn't believe in Medicare for All. He can afford not to. He married a billionaire's daughter.
Senator Klobuchar? Same thing. She doesn't believe every American should be covered in full. She's been in Congress long enough to where she will never have to worry about a medical bill or a procedure being covered.
The rest of us? I guess we can all eat cake or something...
For the same of your self-worth, don't triangulate on this one issue or a living wage. We can do this. We're worth it.
-
Things Trump Did...
https://wp.me/p2KJ3H-3h2
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There is no national Blue Cross. There are a bunch of Blue Crosses, often under the umbrella of Anthem, which is more or less the parent company. Might be good to get the basics straight.
Did “they,” make a ton of money last year? Sure did. Profits were in the 5-7% range. Do their CEOs make a ton? Some do, absolutely.
I find it difficult to see how eliminating that 5-7% gets you enough to pay for MFA. And before you tell me about “waste, fraud and abuse,” let me note that even if you throw in the 14-18% overhead they charge—which includes those exec salaries—I din’t see how you get an average family plan (current cost: just under $19, 000 a year, without dental or vision) down to where you want it.
The money’s gonna have to come from somewhere.
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@Robert
This is but a tiny fraction of healthcare money that is being funneled to the top, and doesn't actually go to pay for care.
The money you speak of is already there. You and I have been paying the trolls under the bridge for far too long.
From Axios on March 11th:
Large Blues health insurer pockets $1.7 billion tax refund
Health Care Service Corp. didn't pay a dime in federal taxes in 2018, according to its latest financial report. Instead, the health insurance conglomerate received a $1.7 billion tax refund, which swelled the company's net profit to $4.1 billion.
The big picture: As Axios reported last year, the Blue Cross Blue Shield companies were on track to retain huge sums of money in 2018 due to the Republican tax overhaul and the growing profitability of their health plans. HCSC was among the biggest winners.
By the numbers: HCSC, which is the parent of the Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas, tallied a net profit of $4.1 billion on $35.9 billion of revenue in 2018 vs. $1.3 billion net profit on $32.6 billion of revenue in 2017.
These numbers don't include the fees self-insured employers pay to HCSC for administrative work.
You can find it in the link I provided in my comment.
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Define "they all work". What is the metric used to assess the plan? Mortality? Satisfaction? Cost?
Healthcare in America is broken both on the accessibility axis - not everyone has adequate coverage - but it is also broken on the axis of efficacy - we pay way too much for what we are getting. Obamacare largely fixed, or attempted to fix, the former but largely did nothing for the latter.
Insurance companies have not demonstrated a willingness or an ability to fix the high cost of healthcare in the US, so why would we think that "Medicare for America" would do any better? Massive regulation would be required to force the medical industry to reform its pricing which is going to result in lots of angry people - their work plans they liked are not going to look the same anymore.
My suggestion is this: Take existing Medicare and lower the age of eligibility to 55. Create a new Medicare for X which is available to all Americans born on or after 2020. In other words, it will take 55 years for the entire country to be moved to the new Medicare. For those born after 2020 it will seem natural as it is something they were born with. No difficult transition for everyone else, other than the usual transition to Medicare when you are older, which by the way, was not that difficult for me or anyone I know. Meanwhile fix Obamacare for everyone else.
@Scott Werden, you are asking people like me to spend the next 25 years paying Obamacare premiums so that insurance executives can keep lining their pockets? You are on Medicare already. Let the millions of people who would be affected by the transition to single-payer decide the level of disruption we're willing to put up with in order to save money and receive better healthcare.
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Thank you Paul! The goal is greater access and more affordability to quality healthcare. There are many ways to get us there that's going to require debate, legislative and persuasion skills and compromise. But as the column's photo shows, if you just slam your fist on the table and insist that healthcare is right, then nothing will get done. All you'll have is a shouting match whether it is a right or not, and if you don't believe it's a right then you'll be labeled a troglodyte.
And while where at it, the Dems should welcome the opportunity to debate on Fox!
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People in America votes in two different ways. One group votes with their hearts. One group votes with their heads. Which is also how the Universal Coverage debate splits up: everyone in the first group is for it, everyone in the second group is opposed.
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Politics is the art of the possible, as the old saying goes. The Dutch system seems far more likely to pass the difficulties of improving our broken healthcare apparatus than Bernie-style pure socialism.
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@David Gallagher, as Aesop once wrote, Possibility is in the eye of the beholder.
One factor that needs to be considered when drafting new health legislation is GOP sabotage. Not only does the legislation need to be designed with economic and practical needs in mind, it will also need to be able to survive the inevitable assault from craven politicians who would prefer that American elders and littluns suffer and die while bankrupting their families.
Drafting effective legislation is hard enough, but with the Mitch McConnels and Mike McCarthys of the world sharpening their knives and eagerly awaiting their turn to hack it to pieces, the job becomes doubly difficult.
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That is why going state by state to get MFA is the better option. Start in Massachusetts that already has 97% of its residents covered with responsible employers willing to work with the state to cover 100%. So have MassHealth run the MFA program and start with state employees and universities and once MassHealth proves they can provide health care better AND cheaper GE will get on board and the dominoes fall.
A plan would impose a payroll tax on employers to replace premiums they are paying and a payroll tax on workers to pay for their share. Cuts the middleman. Also, negotiate drug prices. Need to cut % of GDP paid for care
Payroll taxes on employees aren’t necessary if you start the program by transferring over the people with the best benefits like state employees and university employees. So the process would have to be gradual over several years—we could start tomorrow but it would take several years to finish. So the model is the ACA CSR payments with higher income Americans continuing to pay copays and deductibles and lower income Americans getting the CSR payments. Well off Americans are accustomed to those payments and don’t consider them taxes but that is what they would be.
Insurance is the principle of shared risk. Allowing employer groups (healthy enough to work) to go their own way denies a plan such as the ACA the revenue necessary to pay the bills of those whose medical bills exceed any premium they can pay as a class, covering their medical expenses.
Are we as a nation a group for the purposes of health, or do we continue to game each other with self serving socially irresponsible payment schemes?
But complexity is real:
The only exception I can imagine are DAV's. Their care emanates from a moral obligation to continue the research and rehabilitation they require.
Indian Health Services may be a treaty obligation, though many tribal members prefer outside providers.
Members of Congress and government employees should not be exempt. They need to eat their own cooking.
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Bingo—best risk pool is 100% of citizens. MFA will be cheaper and better so with 100% of citizens in the MFA no new taxes will be necessary. That said, it makes most sense to go state by state starting with a state like Massachusetts that already has 97% covered. The exact same amount of money can obviously cover 100% but it will end up costing less while being better and then employers in red states will advocate for MFA programs in their respective states.
“Obviously?”
Abracadabra!
Healthcare for elected officials. Healthcare for seniors. Healthcare for some of the employed. Healthcare without lifetime limits. Healthcare for those with preexisting conditions.
Why can't we come up with a plan for the rest of the country?
Why can't we improve upon what we have?
Thanks for the link to the Commonwealth Fund report.
But let's assume a Democrat gets in the White House after the next election. That still leaves us with House and Senate full of different opinions on how or if to address health insurance.
So what are the odds that any of the most-likely to pass, in a way that's durable? I'm a bigger fan of successful incremental improvements over long-shot failures.
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as someone who is self employed, I feel the pain of paying a huge amount every month for not very great coverage. If people who are covered thru their employers were aware of how much more they would be paid without the coverage offered by their employer they would be shocked. The other 2 problems with employer based coverage is that it makes workers less likely to want to change jobs and the instability and changeability of pricing for coverage offered by private insurance. Both of these stifle economic well being.
Dr Krugman doesn't mention the French system, though it has been recognized as one of the best, in medical terms, in social terms, and in cost. (France spends far less than we do for a far better result, including lower infant mortality and longer life expectancy.) The key to the French system is its elasticity. A patient is free to choose his or her physician, surgeon or hospital (there are both public hospitals and what are called private clinics). But the central paying authority, by agreement with the profession, establishes a scale of payment for everything from a visit to a doctor's office to a surgical procedure. Most doctors and surgeons work to that scale. Those who, for whatever reason, charge more are still reimbursed the standard fee and the patient, who can obtain private insurance for the purpose, pays the difference. This is quite different from the British NHS where the patient must choose either the state system or a private system. It's not the same as but rather like the Medigap we have for those on Medicare, covering the deductibles and co-pays.
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Whatever else it is called I think the term MEDICARE FOR ALL is specious: it implies that those receiving Medicare are getting it for free...recipients have paid in over a lifetime and continue to pay out of their Social Security, AND underpinning the whole program are PRIVATE INSURANCE companies who bid for opportunity to ADMINISTER AND PAY claims. And that is just the basic Medicare. If you have signed up for any of the other three additions or replacements for the program, MEDIGAP coverage, RX coverage or ADVANTAGE programs those are REPLETE with and only under PRIVATE INSURANCE companies. HOWEVER, here is another part of that which has nothing to do with the Medicare per se: Doctors offices and hospitals using coding methods to get more and more dollars out of Medicare or those who benefit from it. Here's an example: A procedure is billed by the doctor's office at $187 for a 10 minute checkup visit. Medicare pays a total of $92 for the visit. If you do not have a Medigap plan, the remainder falls on the patient...and that is not being paid at the frequently advertised 'Medicare pays 80%'. Democrats must find a way to rein in the GREED on both sides: the insurers and the doctors and that is a very complicated process. And we have not even begun to talk about the costs of prescription drugs! SO stop calling it Medicare at all unless you plan to overhaul a lot of the currently ingrained processes it already contains.
Politicians and pundits need to clarify that Medicare only pays 80% and each recipient pays a premium every month from their social security check. The other 20% is covered by supplemental policies that you need to purchase from insurance companies. What that means is even if people say Medicare for All, it doesn't mean it is free and it doesn't mean there will not be insurance companies.
People complain that government will dictate what is covered and what is not with Medicare for All. That to me should be a preferable option than have the private insurance companies dictate with profit as their ultimate goal.
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There is a huge difference between election posturing across a stable of candidates wanting to stand out as the most progressive liberal in the pack.
In some significant sense this comes down to something an awful lot like what Trump did as he whittled his way through the GOP field of 17 in the run up to the 2016 election. What we got was a Trump victory and the worst Presidency in living memory.
A redo of what happened on the right in 2016 by the Democrats in 2020 would be another unconscionable political disaster for America — a democratic President with a dysfunctional pie in the sky mandate or a Trump second term.
Over and above the Presidency, which so vastly overwhelms everything else, critically what happens with Congress in the election will have a major impact on what actually gets done by a Democratic president.
So to healthcare where understanding why there is still not a concensus model for universal coverage that is something comprehensive, pragmatic, affordable, and not ultra radical.
Paul is right there are solidly workable examples of universal coverage systems that clearly work. What is needed is some amalgam that is appropriately American.
Why not Medicare for All combined with a system of supplemental marketplace coverage options, private-direct-purchase or employer-based. This is effectively what currently exists with Medicare. Those needing other additional government based back up could also be taken care of under the government umbrella.
Mr. Krugman, thank you for succinctly showing your readers the contending proposals presenting by Democrats for improving health care and more importantly the political realities for achieving that goal. Many of the comments here focus only the moralities and ideologies of those pushing the competing options instead of what's needed to elect a president and congress willing to make progress.
The article claims that "none of the announced Democratic candidates has endorsed" a "Medicare for America" type approach, that is simply not true. Pet Buttigieg has been advocating it since Day 1 (or even before), he just calls it "Medicare for All Who Want It." The only reason he calls it that may be because he started talking about the idea before the "Medicare for America" idea even existed? Also perhaps because (IMO) his name for it is almost INFINITELY more meaningful than the one Krugman uses.
I was *really* frustrated with Krugman 3-4 years ago when he seemed to be tailoring everything he said in order to boost a specific candidate (Clinton, against Sanders). He went so far as completely reversing positions that he had advocated in articles a few years before -- and doing it silently, without even acknowledging he'd ever believed differently -- just to support her. I *really* hope this otherwise innocuous claim is not a sign that he is going to shape his ideas to boost a specific candidate this year. With that concern in mind, I searched to see if any candidates have started to say the words "Medicare for America" specifically, and sure enough: Beto O'Rourke just started talking about it yesterday.
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Given the state of the US political system, any universal medical care system, especially one which maintains independent providers, such as Medicare for all X, will discover that it is not able to reduce overall health care costs. Not because it is impossible, but because powerful interest groups who feed at the trough will not allow it. The only way to reduce costs will be to reduce services, especially as benefits are improved and become available to a wider population, without any effort to increase the supply of physicians. Among other things, those who currently receive Medicare benefits will see their benefits eroded away.
2
What I'm taking from all these responses from abroad is a familiar theme: "It's good here, but not perfect." And that's ok! Nothing is perfect. Which I think is Mr. Krugman's point here. Democrats: this will and should be a debate. But drawing a hard line for one type of health reform or the other not only isn't productive, in the long run it won't matter. Trust me; we *will* find something to dislike about whatever system we institute. But it will *definitely* be better than the overly complex, overly expensive, overly exclusionary system we have now, which is objectively and empirically, by any set of data, the worst of any major country — and which, incidentally, has a *major* negative impact on our entire lives. Imagine if we had some guarantee that a major illness late in life would not financially crush us! Imagine how much less we'd feel we had to squirrel away for retirement, just in case we or a spouse got sick. Imagine how much more freedom we'd feel to take a risk and leave a terrible job. It would change *everything*.
2
Dr. Krugman offers good suggestions, but does not really address the most critical issue relating to the cost of care: If we really believe that health care is a right that should be provided for all American citizens, why should we allow insurance companies to skim billions (!!) of dollars from our health care system without providing any actual care? This is clearly why our health care costs so much more than equal or superior health care in other advanced countries. I would be happy with any of the good Dr.'s proposed systems, as long as the illicit and dysfunctional profits of health care insurers are removed from the system.
2
@James
Healthcare is not a right as you are asking other people to provide it to you.
insurance coverage tied to employment is not really coverage, since it can vanish in a moment based on a decision of someone other than the insured. A,ericans may poll as generally haply or satisfied with the coverage they have through ther employer, but there is also a very wide range of what passes for coverage. often, these issues are not really addressed, or only addressed when it's too late, such as during a medical emergency, job loss, or circumstances leading to a move. a healthcare plan that leave 156 million so vulnerable and without recourse or fallback is really no plan at all.
1
I found the PBS Frontline DVD "Sick Around The World" to describe clearly and objectively how universal healthcare systems function in the UK, Japan, Germany, Taiwan, and Switzerland---each a "capitalist democracy". Produced in 2008, it is still worth watching. Conclusion: basic differences, each works well, Better than that of the US..
1
In addition to avoiding disrupting people who are happy with their employer-provided health insurance and the other Realpolitik reasons PK states, there's another reason to avoid going to MFA too quickly:
It's the "who will pick up the phone" problem. That is, if you need to contact a private insurance carrier that knows it's being forced out of business soon, they'll have little to no incentive to service customers.
Instead of transitioning immediately to MFA, adoption of a Medicare option or public option avoids this problem. Further, it would force the private and public insurance systems to compete against each other. Hopefully, that would motivate the private insurers to do a better job and just possibly remain viable.
Krugman either doesn't understand or is eliding an important, politically strategic goal for those, like me, who make "no private insurance" a litmus test for a Democratic primary candidate: to once and for all keep healthcare from being bought and sold in this country.
The truth is that entitlements--a word that's due for a comeback since liberals have abandoned it to the ravenous Right--are immensely popular across the country. That's why the campaign for single-payer is called "Medicare for All." Medicare is appealing because it is universal, comprehensive, and free at the point of service. The phrase is so irresistible that every Democrat with two eyes and a brain is trying to harness its momentum.
Decoupling health insurance from employment will mean that workers won't have to stay in a degrading or dead-end job just to keep their healthcare. That idea practically sells itself, but self-appointed practical thinkers can't seem to see that. Probably because they are lucky enough to be satisfied with their jobs *and* their healthcare. Must be nice!
De-commodifying healthcare is the best way to build durable working-class power that's needed to make many other necessary improvements to this society. That's why it's both ethical and strategic to make it a litmus test for office-seekers.
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@Max
Why are you opposed to healthcare being bought and sold? Food is. Housing is. Clothing is.
@Joe Public
I object to it because we will never get the best health care from a system where the people providing access to it (health insurance companies) have a vested interest in denying us that care. The less service you get for your premium, the greater their profit, so their incentive is to give you as little as possible.
As Mr. Krugman points out, most of the country today get decent insurance coverage and would be highly suspect of any kind of change in their insurance providers (the advertisement blitzkrieg from the Insurance industry and GOP won't help either.) The most practical idea is to fix or refine the existing Obamacare. One small change will make it extremely effective if Medicare becomes one of the options in every market in addition to private insurance. This change will be a subtle change vs. a long drawn fight with misinformed people fighting for private insurance. There are bigger issues at hand like social inequality and climate change, the next government should find the most optimal solution to these problems instead of being stuck in some ideology. I think American people want solutions and not ideology.
A few corrections: My understanding is that the UK has a two-tier system. The NHS is a bit like our Medicaid for those who can't afford anything else, whereas anyone who can afford it gets out of the NHS buys private insurance. Australia is also moving towards a two-tier system. They've started adding private insurance as an add-on to the public system.
Actually my father in law, who can well afford private insurance in England, uses NHS only. Last year he had a stroke and NHS was amazing. He spent a month at the stroke facility then when it was time to come home, a nurse first came by the house to make sure it was suitable and offered to make adjustments with hand railing, hospital bed etc... Therapy happened first at home then off site in a near by village. All was first rate. It’s a year later and he’s doing great.
2
Thank you Mr Krugman, you have once again given me a better way to think about a complicated issue.
Universal coverage is the goal, and how we achieve it is subject to discussion and debate,I for one am willing to have it. That is, the debate and the universal coverage.
1
Prior to my general practitioner referring me to a urologist she had to first to find one who would accept Medicare. Payments to the physician have to be balanced out as well. The golden rule is still in effect. Those with the gold make the rules. Finding a way to compensate Dr.s as well or better than the current situation will greatly improve chances of success.
1
When more people are on Medicare more physicians will take it.
Thank you for this. Voters need a much better understanding of what "Medicare for all" means. The attempt to impose a purity test on Democrats running for president is a recipe for disaster in the 2020 election. Universal health care, as Krugman points out, can and has been accomplished through a variety of differerent means. The public needs to be informed not inflamed by catchy slogans that divide the party and help Republicans in the general election.
1
@Ellensburg
I think it is time to carry water for those who have been carrying the water, not leave them by the wayside like last go around.
I'm not sensing that his is going to be a big problem, given that just about all candidates not named Bernie Sanders seem to be advocating for some kind of hybrid approach or at least a phased and in part market-driven transition to single payer.
To me, the most important question that every candidate should be able to answer about their plan is will your plan actually and directly regulate costs. The ACA has not been successful at reining in costs because at best it tries to address costs indirectly, and like all private insurance systems it regulates access (in and out of network) rather than costs, and it has not cured the massive lack of transparency and lack of consumer market power in the system. We still have insanity like tenfold variation in the cost of a common procedure within the same metropolitan area.
Health care is an inefficient and unfair market. Prices need to be regulated.
Single payer is not fiscally possible in a nation of 330 million where 50% do not pay taxes.
It also does nothing to root out the core problem that has been apparent to all since the 1960s: Big Medicine - the AMA, Big Insurance and then later Big Pharma. Obamacare only fed those beasts, as well as larding 30 million able-bodied millennials onto Medicaid. Most of the country now does receive health care from their employer of the government.
3
@Maggie
You are correct Maggie. Those 50% need to start paying federal income taxes.
Our nation appears to be a free country where people are allowed to live the way they want and if paying for health care through a company which makes a profit based on a person's illness is acceptable let those with money to burn keep their coverage. No problem with that.
Reality however makes note that not everyone has enough money to afford private insurance.
I cannot help but think much of the underlying opposition to universal healthcare is generated by those who fear "free healthcare" will fcrowd doctor's offices with the undeserving, unproductive citizens who now populate many emergency rooms.
Our poor citizenry are taught to suffer in silence, the American way.
Of course, there are many possible formulas. But looking outside the country to see what works elsewhere seems to be taboo in the U.S. Why not, instead of campaigning for one scheme or the other on ideological bases (e.g. liberal purity or belief in the magic of the private markets), start from a short list of what is needed, then search what approach would best realize that in the American context? Or even design a new system based on the real requirements?
Here's what the short check list could look like:
1. Universal inclusion: everybody must be covered from birth to death, everywhere in the country; penalties for opting out unacceptable, either for individual or States.
2. No special provision or cost for pre-conditions.
3. No refusal of services on religious grounds (birth control, abortion...)
4. Shortest possible waiting lists, especially for serious illnesses.
5. The right to improve the basic offering either by paying extra into the public system, or by private insurance.
6. As little paper work as possible, and that standardized and easy to understand.
7. Simple and universal mode of payment, as part of federal income tax or as a separate premium.
8. Fair but effective control of costs: from institutions, health professionals, drugmakers, service providers (ambulance, equipment...). In other words, maximum bang for the buck.
1
Ooops Here I was thinking a "more incrementalist approach" actually WAS progressive. Live and learn.
I remember when Republicans were fighting their battles over ACA, one on their primary arguments against it was that it was putting us on an irreversible path toward socialized medicine. The kind Reagan warned us about. They were right then and it's true now.
And it's not because of some ticking bomb implanted in ACA; it's simply because Universal Medical Coverage for American (which is what we should be talking about) is inevitable. It's only a matter of time. Most advanced societies have it, as you're tired of hearing; and let's be honest with ourselves, we'd have it already if not for a seriously powerful and well funded opposition.
Could party extremists muck it up by demanding too much, too soon from Americans, still punch drunk from the horrors of this political climate and end up mostly just breaking stuff? Yes. Sure. The ideologues on the Right just did it. They're the ones with really nothing to say, standing in the midst of all this broken stuff.
I'm supporting the platform that closes the gaps in coverage for our people and deploys quickly ... and yes I suppose, in deference to the fact that this is a republic, incrementally. But no problem, as all the experts predict, each step puts us squarely on an unstoppable course toward coverage for everyone. Best of all it helps those who don't have all the time in the world.
I realize that columnists don't necessarily get to write headlines. But I am tired of the Times's use of the trite and misleading phrases "purity" and "ideological purity." I have met a few ideologues and self-righteous people in my day. But most progressives understand that politics is not "pure." And why is it that the progressives are accused of being ideological and insisting on "purity," when centrists can be equally ideological and unwilling to compromise. So many pundits and politicians say that progressives must compromise and move to the center. I wish more of them would urge centrists to compromise and move a bit to the left.
2
How many Americans continue to work in jobs they hate because they need the health insurance for themselves or their family members?
How much time and resources do businesses devote to their choice of health plans, their costs, and their worry about whether the costs will erase their bottom line?
It is past time for workers and businesses alike to eliminate health insurance costs as a major preoccupation.
Non-coverage issues, unemployment, uninsurability, medical bankruptcy, age discrimination, adverse selection, loss of pharmacy choices, inability to access your providers of choice.
Free healthcare providers from their worry that they will lose their patients to other networks after each open enrollment.
Uncertainty, insecurity, worry....
When working days are over, will I or my spouse be too young to get Medicare coverage? Will I be able to pay for my health insurance? My medicines? What will happen to me?
5
As one candidate put it (paraphrased): Young people like AOC know that the current 'gig' economy for younger workers is a way for employers to under-employ. If you have to work 3 jobs, each of which limits you to 14 hours/week, (or unpaid internships, etc), you will never have healthcare thru any of those employers. Consequently, they have little incentive to support an employer-based healthcare system. It may be traditional, but only for people like me, now retired. I could get a job anywhere, as a clerical worker, and my health insurance/vacation pay was assumed. We have to understand that this system does not really exist anymore, and current American healthcare is failing the already-struggling working class.
5
According to google, Shakespeare said, "Striving to better, oft we mar what's well. Confucius -- Better a diamond with a flaw than a pebble without. Voltaire -- The best is the enemy of the good. "Medicare for America" would be a politic step towards "Medicare for All."
"...people would be allowed to keep private coverage if they chose — but they or their employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower- and middle-income families." - My concern with this is whether or not the government will be allowed to negotiate prices. If they truely are, and the administration is basically absorbed into existing medicare, then there is really no realistic way the private sector should be able to compete. Even non-profit insurance should not be able to compete. So, what will happen? Right leaning and insurance financed politicians will chip away at the public option to give private insurance an advantage. I guarantee that, if this plan were to ever pass, within a few years, private would ALWAYS be cheaper due to government rigging. I'm glad Paul is pushing for "the most electable" position, because that has never steered us wrong before.
1
"A Medicare for All plan would in effect say to these people, 'We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.'”
"In effect...but trust us," Doctor Krugman?
You do realize that you are uncritically aping right wing attack rhetoric that plays upon blanket distrust of government vs. how it can help citizens. Don't you, Doctor?
And please don't tell me 'Well, I meant that's how a lot of people will see it': how people will 'see' Medicare for All depends entirely on what they learn about its benefits; by paraphrasing a negative idea about it as the main 'takeaway' of people, you are 1) arguing to your readers, 'well what people will think - THAT'LL never fly; but 2) you are making this case by ratifying right wing rhetoric by treating it as objectively true.
In my view, this makes you a shill of the insurance industry - albeit, an unwitting one.
3
Stop. Wanting. It. For. “Free”. Unless you’re willing to be taxed to make it feel free.
1
@Juultje even at a higher tax rate it would be better than my company-provided health care, which pays almost nothing before $6K in deductibles. Get insurance out of the equation, and health costs would improve dramatically.
1
@Juultje relax, you'll be fine. Better off, even. Unless I've got you wrong and you are rich enough to consider buying a sports team, in which case you should be very worried--because you're exactly who we're going to tax to fund single-payer healthcare.
1
From memory, there was a recent Nyt article about hospital monopolies also contributing to high health care costs in the US?
Medicare for America is weak sauce. Medicare for all and if you want more insurance you can buy it.
1
Agreed there is room for debate on which plan is better. Don't get hung up on it.
Bottom line any plan that our app. 30 peer countries have is better than our de facto criminal health care (pre ACA) of be rich, don't get sick and/or don't have a bad life event.
All of them are universal, quality, affordable, cheaper than our system with better results re quality of living stats.
1
You write:
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.
You must keep this in the forefront: the voters remember how Obama promised "you could keep your doctor with the ACA". For that reason alone they will not believe any one ro all of these claims. Much as I would like to see MFA, this cannot advance without a proper message tailored for the masses, who don't message intellect very well.
1
@JAL, you can keep your messaging but I do encourage you to join the masses who have been canvassing, organizing, and rallying for single-payer all across the country. It might be uncomfortable at first, but sometimes there's free pizza. And I can promise that you, specifically you, will be surprised by the intellects you encounter.
@JAL
I love that Republicans keep quoting that sentence when what they strive for is NOT freedom of choice.
What the GOP is insisting on is freedom of choice only if you're rich enough to afford that choice.
Because without healthcare reform, we are going to see the infant mortality rate go up again, aren't we. But hey - deny women their freedom of choice to terminate the "life " of a five-week old fetus, while you're at it, GOP.
@JAL
Trump lies ever time his mouth moves, and this is the one misstatement that is repeated by people who want us all to be the victims of price gouging and inane rallying cries from the GOP about freedom of choice when it comes to healthcare.
When what they really mean is freedom of choice if you're wealthy enough to afford the cost.
I'm a Type 1 Diabetic. I've read in this paper that Germany is selling a bottle of Lilly insulin for $55.00. There are multiple ways that the GOP frames their argument against my having that kind of affordability.
One of the GOP arguments is that the deficit will be raised by another 2 trillion according to their calculations. Odd, isn't it - that the man they endorsed for president has managed to accomplish that same raise in the deficit in less than 2 years - and not a peep out of 'em!
How did they calculate that by the way. I'm not buying it.
I've heard that it's socialism, and socialism is a bad bad word. Last time I checked, our military is also socialism - it's not privatized. Even the internet that Trump tweets his idiotic nonsense on was developed by a "socialist" - government-funded- program called ARPANET.
And a man the GOP has deified - i.e., former conservative Prime Minister Winston Churchill - was evidently for this "socialist" form of healthcare. He was very clear about it:
"“The discoveries of healing science must be the inheritance of all. That is clear: Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion…."
Quote Churchill's advocacy back at them. Because this IS a fight for our lives.
4
How many times do Dems get to retreat from universal coverage before we quit giving them a pass on their failure?
How many times must the insurance companies and drug companies defeat universal coverage before we accurately label them the enemy, and enact universal coverage?
3
At last Professor Krugman is making a great deal of sense. He understands that the Dems are assembling a circular firing squad that will re-elect Trump.
2
For additional context, check the rankings from the World Health Organization and The Lancet below. Notice that blended systems are well represented.
Since blended systems can be just as effective, they deserve to be part of the discussion, do they not? Plus, they also have the added benefit of an easier political sell.
But then again, without a purity test, how am I going to get a virtue fix out of this topic? Krugman is trying to take all the fun out of it. :(
From the WHO
1 France
2 Italy
3 San Marino
4 Andorra
5 Malta
6 Singapore
7 Spain
8 Oman
9 Austria
10 Japan
37 USA
From the Lancet:
1 – Iceland
2 – Norway
3 – Netherlands
4 – Luxembourg
5 – Australia
6 – Finland
7 – Switzerland
8 – Sweden
9 – Italy
10 – Andorra
29 - USA
2
I can't imagine what business would want to keep the current system. As a small business owner each year we waste way too much time figuring out what to do about our insurance. It is an exercise in stupidity since all options sort of suck, maybe if we were made of money it would not be so. And do large businesses really want to employ hundreds of people to work on this giant distraction, not to mention maintaining large office buildings to house them? Talk about loose loose.
Medicare is the perfect system, ask anyone on it right or left. I imagine when Medicare was created there were more than a few folks over 65 receiving employer health insurance, and I bet most turned in their resignations the day it happened as opposed to working into their golden years.
And lets not forget about the fact that most people on Medicare have supplemental insurance for the few things that are not covered so the argument that insurance jobs will disappear is not well founded, in fact it will probably become more profitable with not having to foot the overpriced bill for someone in truly bad shape.
You will be able to buy a supplement and keep your doctor and not have to wait for a procedure.
5
@Norman
It’s always been a mystery to me why the heads of the Big 3 automotive companies did not campaign hard for a medicare for all type of system.
I did some consulting work at GM in the 1980s when Roger Smith complained that GM’s biggest supplier was Blue Cross/Blue Shield (back when it was still not-for-profit).
All those imported cars are made by companies that didn’t have to worry about that kind of an expense.
Whey don’t CEOs do the same?
I can only guess:
1st - CEOs are a kind collective group and their union is the Chamber of Commerce. They work to keep their salaries skyrocketing at the expense of everyone else. It’s part of their union’s dicta keep insurance private because some of their members are high dues paying CEOs of insurance companies.
2nd - if insurance is not based upon employment, many people leave the work environment all together and many more go off and do things with lower margins but is closer to what they love to do. If you like to cook, you can open up a store front, serve lunch, make your money, then go home to your family. This would reduce the pool of workers and drive up labor costs. Health Insurance makes work a form of peonage, indentured servitude, or modern serfdom. It’s another reason why more and more Americans hate American style capitalism and American CEOs.
3
I'm with you, Paul!
Thank you Paul Krugman for your expertise and the comparative information. Physicians want it. People want it. We should follow the Brits – “Medicare for all.” Under the current system the costs for visits, tests, specialists, and operations are at the extortion level. When you are weak and need help the costs are cruel and inhuman. In many cases they are un-payable.
1
For those old enough to remember we once had something close to a single payer plan and it was very successful , called blue cross and blue shield . That all changed , I believe , when Tricky Dick decided that the system needed competition , for the good of the people . I guess he never heard the saying = if it ain't broke don't fix it . Well it's sure as heck broke now and I'll believe it will be fixed when pig , I mean when insurance executives in their 2000 dollar suits fly .
Back in the 1990's the state of Oregon pioneered a public health insurance system that prioritized coverage for some conditions over others. Dr. John Kitzhaber was the governor. The system worked. It would not pass the purity test today. But you can't please all of the people all of the time.
Paul Krugman is preternaturally smart about public policy.
Or maybe he's just a good economist.
Surely both.
Think about it for half a second.
Your employer says you can continue with your BlueCross, Aetna, or whatever insurance plan under the same terms as before. No foolin'.
But we're going to put this Public Option version of Medicare, actuarially sound, cheek by jowl with your Aetna, etc. plan come next open enrollment cycle.
Watch the premiums for your Aetna plan continue to go up, for among other reasons because the Boards of private insurance companies think their CEOs are such geniuses that they regularly award them 7, 8, and even 9 figure bonuses for their cleverness.
Then watch how Charlie's premiums for his POM (Public Option Medicare), while they may go up, go up much more slowly.
Why?
Because Medicare can already bring 60 million consumers to the table when it bargains for prices, while Aetna and the rest of them can only bring fractions of that many consumers to the table.
Who is going to get the better price? For the same doctors, the same hospitals, and the same prescription drugs?
This is Econ 101.
And the scenario has already played out with privately financed Medicare Advantage plans, which only survive because of Republican willingness to subsidize them despite their unnecessary - executive bonuses again! -- costs.
Fact that most people don't know. Most major private insurance plans already use the Medicare schedule for most reimbursements.
@Arbitrot Okay I thought about it for a half second like you asked and I still think single-payer is the way to go. And since it's widely understood that Medicare for All will reduce costs and improve outcomes, I didn't feel the need to finish reading the rest of your comment. If you've got some spare time though I recommend this UMASS analysis of Medicare for All: https://www.peri.umass.edu/publication/item/1127-economic-analysis-of-medicare-for-all
Democrats should unite under "Healthcare for ALL" and not "Single Payer".
1
Buy a toaster at Walmart and an insurance policy is offered at checkout for your toaster. Buy it and if your toaster gets sick under warranty some guy somewhere might fix it if you pay shipping. Sorta how all private health insurance works: you’re eligible to buy it if your warranty’s good but don’t be surprised if they’re playing you for a sucker.
Mr. Krugman begins by castigating - quite sensibly - "third order" analysis, whereby "pundits" speculate on HOW THE electorate will react to this or that proposal.
And then - well into the article - he does precisely that.
This - Mr. Krugman - is as smart as they come, in my opinion, so this is all but inexplicable.
For well over 20 years, first Bill Clinton and then Hillary Clinton tried to guess (and then deliver) what their pollsters divined that "the people" wanted.
Of course, Bill accomplished zilch that way ... and Hillary - well, you know how THAT turned out.
Mr. Krugman points out how VERY regulated the very successful Dutch insurance-company-based plan is.
THAT is the one thing that our country has never done consistently well. Over the last 5 or 10 Presidents - clearly a mix of Democrat and Republican - the FDA has ??
By trying ever so hard NOT TO "get in the way" of pharmaceutical companies, we have high-priced drugs of uncertain effectiveness in many cases.
The FAA - even before Trump - BARELY helped make flying safer; they certainly flunk every other test of effectiveness.
And on and on. We live in so FEROCIOUSLY and unbridled-ly a capitalist system that the ostensibly "regulated" ALWAYS wind up running things. Once you recognize that it was always thus, Mr. Krugman's "many paths" argument crashes back to earth. Unfortunately, he & the Times will only really endorse a candidate (e.g., Biden) who picks this least-likely-to-succeed path!
1
I love the way we are always saying how America's healthcare system comes in last compared to western nations. Meaning.......what? We are also the undisputed leader in medicine. Our universities teach the planet, billionaires from around the world fly into the Cleveland clinic ( Not Copenhagen) the last medication a Canadian pharmaceutical company discovered was insulin .....1948. We do have our problems in healthcare cost and delivery but if stories are not balanced and seems a bit off it becomes agenda driven...becomes propaganda.....becomes a bit like fake news.
@DJ
The issue is access to medical care, and in that area we are dead last among advanced nations. The other issue is outcomes we again rate pretty low. But we are number 1 in paying more that any other country for health care and drugs.
Makes you think that U.S. people are patsies taken advantaged of by the ultra wealthy.
Well, many are tired of paying for everyone but their own, I hope Democrats come along.
Not making healthcare a purity may kill some of us. What a luxury you have to support candidates whose policies don’t determine whether you or those you live live or die.
1
‘Access’ to healthcare will leave at least some people out of the system. Medicare for All means healthcare for EVERYONE regardless of your ability to pay.
PK doesn’t care about the critical distinction because he’s rich.....but the rest of us should!
1
"...the Commonwealth Fund provides ...survey of major nations’ health care systems....the three leaders are Britain, Australia and the Netherlands."
It's not a a coincidence, then, that right-wing Populism is surging throughout the developed world and, surprise, surprise, ESPECIALLY in ...Britain, Australia and the Netherlands! People in these countries DO have wonderful healthcare systems. Now, if they could only afford them! It also isn't a coincidence that amidst all of Krugman's huzzah's the word "cost" appears only ONCE. If you want to rank the strongest (lowest unemployment, fastest growth) economies in the world, you can use the Commonwealth's rankings again: just turn them upside down.
"A young man who isn't a socialist hasn't got a heart; an old man who is a socialist hasn't got a head." - Georges Clemenceau
1
@Connecticut Yankee, stick to referencing Twain, at least he was witty. Populism is surging because exploited people hear elites talking about "fast growth" and "a strong economy" and wonder why they are working more but making less. The right-wing has capitalized on this feeling because liberals either denigrate people who feel that way or ignore them, and the left is historically weak.
1
Venezuela!
I guess I shut you guys up.
...Is what the Republicans are going to say. They are as empty of ideas as...well...Venezuela will be of people. What is one of the main reasons Trump is still mad at McCain? McCain wouldn't abolish Obamacare and throw millions of people off the insurance rolls.
How refreshing it is to see a party - the Democratic Party -actually debating different plans as a way forward in helping improve the nation's healthcare. Democrats, don't blow it!
Medcare for All is a good bumper sticker. Let’s not nitpick ourselves to death.
1
A nice dose of badly needed common sense.
Beto already came out in favor of Medicare for America. Also Buttigieg.
Physicians are the ones who actually take care of patients yet this article does not mention even in the least any of their opinions.
Why aren’t their opinions included?
Edward Volpintesta MD
I live in Nevada during the winter. Before Obamacare, I could get a primary care doctors appointment in 10 days. Within two months of its passage, it took 2 months. Today it takes 6 months and I only get ten minutes with him. My doctor could not pick me out of a police lineup if his life depended on it.
Obamacare is driving doctors out of the profession. We are headed for a system where everyone will have insurance, but only the rich will be able to see a doctor.
Dear DEMS, thanks for nothing.
2
@Joe This is not due to the ACA per se, but the fact that we don't have enough doctors to serve our increasingly sick population. It's true that under the ACA more people have access to the healthcare system and therefore we need even more doctors. And many folks who have lived without access to healthcare for so long are very sick as a result.
Would you want to return to a system where the poor can't see a doctor, or maybe we should just train more doctors?!!
@Joe
Rediculous. LIke a Doctor is going to leave his profession so he can go write code in Silicon Valley or practice law in New York just because he doesn’t like the ACA?
If there are longer waits, then its because more people can now afford to get the care they need to stay alive.
You make it sound like you wish poor people would be left without access to care, die in the streets, so that you can have a shorter wait time to see a doctor.
So, I’m sorry you have to wait longer. But you should be celebrating the fact that some of your fellow Americans have access to health care than they had before.
Remember what Gandhi said: “Poverty is a kind of violence, the worst kind.” Being too poor to get health care insurance is one way of how that violence is manifested in our society.
If you are truly peeved, you should be writing the AMA and ask them to allow more people to enter the profession so that there are plenty of doctors to go around to serve your community in the way you want to be served.
Just a quick look around for a good national health plan finds this in quotes:
"Switzerland and Singapore, where state health spending is far lower than it is in other industrialized nations. Neither Switzerland nor Singapore could be described as libertarian utopias—both systems contain aspects that conservatives
wouldn’t like—but they provide powerful examples of how market-oriented health care systems are more cost-efficient than socialized ones.
I’ve described Switzerland as having the world’s best health-care system. In Switzerland, there are no government-run insurance plans, no “public options.”
Instead, the Swiss get subsidies, much like “premium support” proposals for Medicare reform or the PPACA exchanges, from which Swiss citizens buy health
care from private insurers. The subsidies are scaled up or down based on income:poorer people get large subsidies; middle-income earners get small subsidies; upper-income earners get nothing."
Hundreds of ideas are around for America to have a good plan to cover everyone and have options and freedom with it. And at a price that can be affordable. We can do it but there is much education of the public needed and power forces will not like it. But lets do it.
I would love to live in an America with Medicare for All, but I worry about the transition. Insurance companies are also employers, and what will happen to all those workers? Also, I believe that Medicare will cost less than private insurance, but I don't necessarily trust my employer to pass the savings along to me in the form of higher salaries. It seems to me that the Medicare for America approach is likely to yield a smoother transition and allow people more choice and control.
One aspect is not mentioned, at least the voters in Australia and The Netherlands believe that government will do the best it can to service them, and if not, that can be changed though elections. In fact, Canada is even a better example, Canadians voted for a healthcare system that excludes private insurance companies, so that rich people has to wait in line for treatments just as poor people. In the US, the elected representatives are not representing us people, thay cannot be trusted.
1
Given the admonition against litmus tests, particularly played out in a primary season, it is important to debate the real options. From my point of view, as an employer of hundreds of people in the USA, there are problems on both the Medicare for All and the Medicare for America.
I can't argue with the Professor that people like their employer paid healthcare. But there are vast differences between companies level of support for employee health care. The costs are so significant that health care options provided to employees becomes a major competitive determinant for industries which tend to be more dependent on the cost of labor. Some companies pay for all of an employee's health care no matter which plan is selected. Other companies pay for half of the employee's selection. Other companies pay for a basic plan so that the employee must pay for "extras" such as dependent coverage, or a private doctor network.
Employer-based healthcare is no panacea; to be an effective choice it must be more effectively regulated (think Netherlands). I believe this is a key issue for the democrats because it seems unlikely to me that a Medicare for All can get past the cultural meme and accusation of "socialism". Further, can we just imagine the intense lobbying and tremendous spending the private health care industry will exert against a Medicare for All plan? Awesome!
Let's all support a Medicare for America that includes regulated plan designs for employer-provided coverage.
I share all of Krugman's concerns about Medicare for all, but would also add that I lack confidence in the government's ability to smoothly transition the whole country to it. A bumpy roll out would be disastrous given the skepticism it's likely to encounter, even if it would end up being better in the end.
@KM, well if republicans will argue in good faith this time, it will be much smoother. If they can try to make the rollout smoother, instead of throwing rocks onto the tracks, and then fanning the flames of 'skepticism', it will lead to progress. I know it's a wierd concept, but Americans don't need to die needlessly while trump snipes at pretend socialist dangers....
Currently through taxes, I am already paying for just about everyone but myself - Washington has it, the state capital has it, the schools have it, the hospitals have it, the college has it, the elderly have it, the poor have it. It is really sad to hear anyone not extend it to all.
Words matter. Even if Medicare for all is the right approach, selling it to the public, especially those on the right, will be hard. Instead, if the option is to buy into Medicare for anyone who wants it but not mandatorily so would sell. This will be supported by the older folks who are actually unaffected by this - those on Medicare already - but their influence is worth getting as they are generally on the political right. I am sure they will advise their younger generation that Medicare is not so bad after all. No question, the cost has to be supported by taxes and I like the idea of a capped 'floating' tax whereby taxed money is returned at the end of the year if the expenses are lower.
We know corporations are not people but they do have clout. If a majority of corporations - obviously the medical insurance companies will not join in - see that their expenses are lowered by a Medicare buy in, they will lend their influence.
It will be a slow process but I believe a start was made with the Affordable Care Act. We cannot let our efforts to improve the medical delivery system wither as a result of Republican intransigence.
I think one politically viable option is to expand Medicare to people <21. Does anyone want kids to go w/o needed care? Do we blame 7 year olds because their parents can't afford care? Medicaid already covers nearly 1/2 of kids- why not expand it and take the burden off of employers (and parents)? And we know that it's always more politically viable when a benefit benefits everyone, not just the poor.
While this could be done via a Medicaid expansion, it's not a good idea because their payment rates will bring resistance from the medical establishment and Medicaid has a state cost share. Just shift all kids from Medicaid and private insurance to Medicare and pay for it with a (fairly small) energy tax.
Thank you for pointing out that, of the Democrats’ rival health care plans, “both of them would do the job.” It reminded me of the 20th century industrialist Henry J. Kaiser, the co-founder of the non-profit Kaiser Foundation Health Plan. Frustrated by America’s inability to provide healthcare for all of its people, he argued that a series of rival nonprofit health plans like his own could do the job. As he told the National Press Club in 1954, “I can’t understand, for the life of me, why there should be any conflict or controversy over any plan that brings comprehensive, high-quality medical care to Americans at a lower cost.“ That was 65 years ago and we are still arguing — as you point out, the only advanced country in the world that continues to be incapable of doing the job. (Henry Kaiser is buried in a cemetery in my neighborhood. At times, I could swear I hear him spinning in his grave during healthcare debates!)
Healthcare in the USA has first and foremost a cost problem. As long as our healthcare cost twice as much as other developed nations, for the same service, we will have big problems. Medicare for all or some other permutation will result in an unsustainable healthcare system, unless costs are driven down.
These grossly inflated costs are the results of profit motives in the healthcare industry. Furthermore an increasingly obese and sedentary population helps to sustains these grossly inflated costs with unrealistic expectations for healthcare.
Please don't let the perfect destroy the possible this time...
It would be very helpful if pundits would stop with the play by play calling and add some depth of understanding to these stories as they develop instead of dwelling on the personalities and the guessing what the public might think of this or that.
We are up next to the last democratic election if we don't play this one right.
I agree with Mr. Krugman: Let people with employer-based coverage keep it. But, also offer them and all others a public option. If this public option is seen as better option, HMO's will have to improve their coverage-to-cost ratio or go out of business.
"almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
There is a huge difference between being satisfied with current employer based coverage, which I would agree that I am satisfied, and saying that I expect that this is sufficient. I am concerned that employer based coverage will continue to increase in cost and decrease in quality. I also do not like being dependent upon an employer who offers insurance in the first place, both for myself and my kids. What if I become unemployed?
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@Kent Exactly, I know of nobody who likes their insurance company especially if they ever have to use it, not to mention deductibles.
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I think it's unlikely that Democrats will be given complete control of the legislative and executive branches. Even if they do we still have a quite conservative Supreme Court. Whatever deal is negotiated between Republicans, Democrats, and the insurance lobby is going to look nothing like anyone's talking about now or really wants. I think we all have to be a little more realistic about the future. Like the ACA, whatever improvements will be incremental, people will get used to them and then the next step can be taken.
Well said Prof Krugman!
As your late fellow economist Ewe Reinhardt said so well "it's the prices stupid!" which is the core problem.
Rand has been doing some excellent work on behalf of a number of employer coalitions and has demonstrated the core problem: some health plans pay between 200 to 500% of Medicare (yes this is true. One health system in Indiana is paid 5 times Medicare for outpatient services!).
But as with everything in health care we should be thinking "do no harm". We need a well thought out and data based glide path to rationalizing pricing that allows health systems to deal with how they get through this when commercial payment rates are reduced over time. We did not get here over night and we will not get out of this jam overnight either.
The fact is that if every health system was paid Medicare rates our overall costs would look something like the OECD countries. But if we go there too quickly we will but the delivery system under unacceptable financial risk.
There are many ways to fix this and, I agree, that a public-private approach makes the most sense. We need a single pricing regime. It will be attacked as "price controls" but that is basically how most of the Euros do it.
The usual outstanding column from Professor Krugman, and the usual excellent reader comments. All I'll add is this - whichever system Democrats end up proposing should be based on the recognition that unless the power of the ultimate payor in the system is roughly matched with the power of the providers, and here I mean market/[pricing power, nothing will change. The single biggest fiction about the current US healthcare system is that we benefit from so-called "free market" characteristics of free choice and readily available price information. It is a virtual monopoly, with the characteristic high prices and inefficiency of same. And the ultimate beneficiaries, meaning us, are but lambs to the slaughter. And apparently willing, and willfully ignorant, lambs at that.
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Anyone who wants to eliminate the private insurance industry needs to consider how you would “disrupt” healthcare without putting millions out of work, driving physicians out of practice, throwing financial markets into a tailspin, and ultimately killing a lot of people because of the chaos. A single payer litmus test is naive and a dangerous path to election of a Democratic President.
The issue we must address is universal coverage that provides healthcare for all - not necessarily Medicare for all. A public option to provide competition in the market will stabilize costs and provide opportunities to provide special services for chronic care and complex patient populations.
Common sense makes sense against a senseless opponent.
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Frankly I don’t care what you call it. This is my third year being penalized for not paying for insurance I already can’t afford and couldn’t use because I can’t afford the high deductible and co-pay. I want to be taxed from my regular payroll and as a part of my taxes to provide me any/all health care (and I mean ALL including mental health, vision, dental, physical therapy, etc etc) with no cost to me out of pocket, period. Basic prescriptions (birth control, insulin, antibiotics, etc etc) should all be free for everyone, period. Get rid of the insurance SCAM. Get lobbyists OUT of government. These folks need to stop profiting off the sick and dying and get real jobs.
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This sounds an awful lot like the preaching from the stick in the mud Clintonites who demanded people who needed more from their government to wait some more and ignore that crazy Bernie person. Why is it that this lot feels entitled to always tell anyone not of their opinion to change conveniently never having to consider let alone make changes themselves. Note, you were wrong. Clinton lost no thanks to your lot making so many feel left out they didn't even show up to vote.
It's not about litmus tests of those willing to change to have what the rest of the world has. No. It's about the stiff stoggy middle needing to get up off their keesters to move the country where it needs to go.
Considering what Boeing has pulled off, making safe planes an added extra at a cost and how our policy is written by lobbyists for the industries that benefit the most out of the arrangement, I don't trust any policy health insurers would write themselves to get around any regulations they'd have to operate under.
It's not a litmus test at all. It's about understanding the crypto-lobbying class that has always and will never stop buying health care from working Americans who desperately need more from the comfortable center who can afford to help out backing more aggressive policy.
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Americans argue endlessly about how to pay for health care, education and infrastructure, yet they've funded two wars on credit and given a trillion dollar tax cut to billionaires.
American leadership is an oxymoron.
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Who are these mythical people who are happy with their employer plan and want to keep it? I don't know many of them. My guess is they haven't had to really "use" their plan, and don't know how draconian it gets when they do. Personally speaking, I'd be happy to jettison the employer plan I have in favor of Medicare for All. My employer's plan is byzantine, endlessly changing costs, and due to an arbitrary switch in medications it "decided" to cover, nearly cost me the use of a medication I need to take on a daily basis. This required two weeks of ever escalating calls to the insurance company, repeated calls to my doctor's office, their nurses, and a letter from my doctor. All from an arbitrary change. It was enormously stressful. And you think that's okay? It's not. I could give you a multitude of additional experiences, including denial, delays, and harassment, beyond the one issue I mentioned above.
Let's not also ignore the reality of job lock. Most people keep jobs they're unhappy with because of health benefits.
The reality is, the "health" insurance industry is a barbaric racket, designed to extort us for as much as we're able to give, and more. And if we can't? Either go without, get sicker, or die. That's inhumane and inexcusable. A system that grotesquely rotten cannot, and should not, be reformed. It's time to scrap it and begin again, with the actual health and well-being of the American people in mind for once. We need Medicare for All.
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@Dominic
I am very happy with my private insurance and i am paying thousands of dollars less than what would be required of me with Medicare for all. Maybe you need a different job.
Exactly. Some of the Dems' health care proposals are out of left field, others too incremental. But some of them will morph into something that's a lot more sensible -- and better -- than we have now. So it's way too early for the nattering nabobs of negativism, i.e. the pompous punditry crowd, to start tearing them apart. As for Trump criticizing McCain for his thumbs down on repeal and replace Obamacare, there never was anything to replace it with and the GOP "replacement" remains an empty black hole in the firmament.
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Once again, the problem is not on the insurance side of the equation. It is, instead, on the cost side of things. This morning's NYTimes op-ed on the high cost of insulin illustrates the problem perfectly. Congress has so tilted the marketplace for America's big healthcare and pharmaceutical companies that they have virtual monopoly power. In response to Wall Street demands to improve quarterly earnings, they raise their prices with total impunity. No-one in Congress wants to get labeled as anti-business or worse yet, a socialist, so they refuse to engage with the actual problem. The sleight of hand move is that Medicare for all or whatever plan they espouse will somehow accomplish what they are afraid to do themselves, restrict excessive profit-taking by leveling the marketplace in favor of the consumer. There in lies the spineless, feckless, cowardly character of today's generation of political leaders.
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Pass a bill lowering the Medicare qualifying age to 0. Every member in congress stands naked before their constituents and goes thumbs up or thumbs down.
Then work out the bugs.
The adjustment period would be far better than any watered-down, compromise-heavy program (like The ACA) that would result after the hospitals and drug lords weighed in.
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Dr.Krugman, thank you for the underlying point-- the press coverage spotlights the fluff generated by the pundits in response to the chaff thrown out to shift attention to the age, the gender, the inexperience of the people proposing real change--especially if they are women! It's just lazy journalism!
Why don't they play nice? Because playing nice hasn't worked. Obama bent over backwards to play nice on Obamacare, spent years working to find consensus on a plan based on a proven Republican concept. Didn't get a single R vote!
The roadblock needs to be broken by someone, some real leader, presenting evidence based policy proposals in a way that the empty objections of the mean-spirited opposition are punctured as soon as they hit the air.
Medicare works. There are many ways to fund it. The net effect will be to save huge amounts of money.
And the common good is made better when everyone can receive health care, and nobody is bankrupted when their kid gets sick.
We already know the answer: the Sanders camp will deride and destroy any Democrat who does not endorse him. And it's not just on health care. Sanders himself will stay just above the vitriol, while allowing his surrogates and loyalists to scorch the earth. They don't care about electing a Democrat because they are not Democrats.
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@Steven Barth You mean do exactly what Hillary did to him, he is a far better person than that.
Medicare for All Who Want it! That's the right path, essentially a rebranding of the public option. The idea of taking away the insurance people currently have is just plain dumb. It plays right into the "these crazy socialists think the Government should control everything" Republican messaging and will be hated by tons of normally reliable Democratic voters--think labor unions will be happy about trading in the gold-plated private health insurance plans they negotiated so hard for so they can get Medicare? Covering the uninsured with Medicare will provide universal coverage and by offering it as an option to private insurance you create real competition private insurers will have to deal with to continue to exist.
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No more playing these games, corporate for profit health care is a complete disaster. Private heath insurance companies are parasites who add zero value. Medicare for all.
We don’t need no stinkin’ Insurance Companies. They are purely parasites, existing only for profits, denial of benefits, and enriching their Upper management and stockholders. The model we should use is Medicare for All, and the best example is the Military System, when well funded and properly administered. So, yes. Bernice down under. With or without Bernie, tk.
The people most opposed to this are raking in the bucks from the current disasterous “ system “, or are paid to do nothing and maintain the status quo.
Medicare For ALL, or DIE. Quite Literally.
156 Americans earning that benefit tax free, whereas those in the Individual market using after tax dollars to buy a very much inferior product.
As a so called economist, that would be a good place to start. And what happened to the House than ran on healthcare? Crickets.
To busy figuring out how to regain power. They could care less about the people
I'd be interested in knowing how the Netherlands system of private insurance gets rid of the fat while satisfying the population's desire for top-notch care and the insurance companies' desire to book profits.
The Dutch are nothing if not pragmatic. We ought to take a hard look at their system and see if we can lift their ideas.
A purity test? No. But what’s more important to get right than providing cheap, quality healthcare for all?
My memory is that Mr. Krugman was a big advocate of Obamacare, a pretty tame and ultimately pretty useless solution to a huge problem. So let’s not call this a purity test, more like if-you-don’t-support-socialized-medicine-you’re-not-worth-voting-for. Does that sound better?
There's something weird about this country. Every other first-world nation manages to pay for its citizens' healthcare; here, it's "get sick, go bankrupt and die." Just as every other nation manages to avoid fatally shooting hundreds of its citizens every year, while here it's "you can never have too many guns." And the NRA pressures our weasel politicians to make it illegal for doctors to ask whether their patients have guns in the house. There's one political party that wants Americans to be healthy and safe; the other, unfortunately, prefers to pursue the highest profit, regardless of the damage that might be done to the citizen, the environment, and the country itself. And so far they've been winning.
Who are these people who are satisfied with the health insurance they receive through employee? They're satisfied with the in-network, out-of-network nonsense? (Out-of-network, but there's no provider in-network within 50 miles?) They're satisfied with high premiums plus out-of-pocket caps that can run as high as half your gross pay? I don't know anyone who's satisfied. In the last 15 years, I have literally never heard anyone I know say "wow, I was worried when they had to rush me to the hospital that I wouldn't be able to pay my bills, but I was pleasantly surprised at how much insurance covered" or "gee, that procedure didn't cost me nearly as much as I expected."
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Only Bernie Sanders and today's so-called "Progressive" Democrats could figure out a way to lose in 2020 to someone like Trump...a man who everyone in the world except about 60 million Americans knows has severe mental illness and is a threat to humankind. And I'm sure the Dems will give it their best shot to hand Trump a second term. The nation's only hope to avoid that happening is if enough Independents and Republicans vote against Trump.
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Key issue for US is controll costs...HMO’s , hospitals, Drugs, MD’s. The whole incredible profit-making system will not allow even a mixed care for everyone solution.
I am in favor of a single-payer system because I know from personal experience, having lived in Europe and Israel, that it works better than the clumsy and expensive American healthcare. However, Medicare for All has now become an empty slogan pushed by populist demagogues such as Bernie Sanders. I am suspicious of anything he proposes because I reject his underlying socialist ideology. This said, I think the German or Swiss system of regulated private insurance would work best because it offers the possibility of supplemental and graduated access. Any kind of single payer requires rationing - this is just a fact of life. So it is important that above a certain level people have the option of buying better care if they have the means and desire to do so.
Sigh.
Obamacare is largely modelled after the German system; European countries do not have simple single-payer systems. Israel sort of does, but also mandates insurance and only covers about 60-70% of costs.
For decades the American people have used their elected representatives to express their desire to be sick and die young and bankrupt.
The current system fulfills that desire. You can't force people to want a long healthy life.
Purity shmurity. I'm a Type 1 Diabetic and is is purely life -threatening, chronic condition.
The Republican party is threatening my life. How many multiple ways is their venal anti-me / anti-healthcare rhetoric going to to do me in in the long run - both financially and even worse in adversely affecting my health and affecting our mortality rates.
Quote Churchill to them when it comes to Universal Healthcare, i.e.,:
“The discoveries of healing science must be the inheritance of all. That is clear: Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion….Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”
The problem is that many Democratic (and pretty much all Republican!) politicians ARE shills for corporate interests.
So when they tell me “This plan, which happens to keep insurance companies in the loop and mandate an even larger customer base for them, is really great!” I feel entitled to be skeptical. Looking at their campaign donors makes me more skeptical. And looking at where their children, spouses, siblings work makes me even more skeptical. (Can we please have more reporting on these family connections?)
There are VERY few politicians who I trust to have average people’s best interests at heart. That doesn’t mean they are always right. But at least they aren’t gaslighting me for personal gain.
Among that very small group I would include Warren, Sanders, and AOC. Unfortunately, Paul, your favorite centrist politicians are not among them. When Obama and Clinton popped out of the White House, they hung around with billionaires and commenced building hundred million dollar fortunes. We can see what their values are.
Maybe Jimmy Carter can stop giving back to his community for 10 minutes to opine on health care, because I trust neither the wealth-loving Clintons nor the Obamas, or nearly anyone in that money grubbing, bankster loving wing of the party.
Should there be a health care purity test?
No.
But until I hear people I actually trust support a particular plan, I’ll remain skeptical.
Good policy of any kind is virtually impossible to achieve with our dysfunctional Congress.
Never underestimate the Democratic Party’s ability to make improvement the enemy of perfection, to snatch defeat from the jaws of victory.
You don't need to worry your head about this. The Democrats are so busy shooting themselves in the feet that there's no chance they'll win in 2020.
I have no idea whose idea it was to call for 'reparations' when we can't even get Medicaid expansion. And where did 'Socialism' come from, when no Democrat is to the left of Harry Truman? And for a bunch of politicians who can't stop talking about 'reparations' and 'Socialism' to call for a 'Green New Deal' besides, in a country where a carbon tax is unthinkable?
One of the problems with 25 candidates, is that each one has to try to out-do the others in order to attract attention. The Republicans did that in 2016... Wait... Maybe there's something there...
When Donald Trump promised to build a wall across our southern border that Mexico would pay for and repeal and replace Obamacare with "better, cheaper healthcare for everybody," he got elected. Trump didn't promise to "phase in" the wall, a few miles at a time, or to "transition out" of Obamacare so as not to force people who like their Obamacare insurance into a new plan and disrupt insurance markets. No. He went big and disruptive. He lied about Mexico paying for the wall and he lied about better and cheaper and everybody covered. Why, then, should Democrats be so wimpy about Medicare for All?
In comparison to Trump's steady stream of lies, how could any plan have a credibility problem? Whatever it is, just make it big and shiny -- run commercials with people standing up out of their wheelchairs and walking. Show the people that you get where they're coming from.
Aren’t all the advocates for an abrupt switch to Medicare for All tiptoe-ing around the “other” elephant in the room? By that, I mean abortion coverage. How will that work in a country that is so divided on this issue?
Any Dem gets my vote in 2020 if and only if s/he supports a single-payer system (Medicare4all) unconditionally. Otherwise I vote Trump!
This is a column that practically begs progressives not to nit pick about the variety of Democratic health care proposals on the table. And what do our commenters do? Nit pick, demanding ideological purity and rehashing debates from 4 years ago that have resulted in - nothing good because Trump was elected.
Why is anyone talking about healthcare costs before talking about the chronic clinical failures of our so-called healthcare?
Why is no one talking about making it the best ranked - rather than the worst ranked - in the world?
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Dr. Krugman you are not wrong---while I would think most voters would say, yes, to medicare for all, if in the next breath you said, oh, we are taking away your current coverage, the answer would be no. You need a gradualists approach to this issue---shore up Obamacare and then nibble around the edges of health care expenditures---e.g. expense of drugs.
Why not test the hypothesis of the efficacy of the three world's leading healthcare methods on large sample populations? Perhaps, California?
Exactly wrong. By all means make it a purity test. If some one cannot commit even to public healthcare, no one needs them as a President.
Illness prevention, cost reduction, blah, etc - Electability is the issue. Sanders is boring, Warren is a scold, Harris is a screech, Booker is a bore, and our Insley is an Al Gore waiting to be defeated. I don't know. Maybe Beto. At least the kids will get out and vote.
This nation has a stark question ahead of it; will we care for each other? In the current politically inflamed atmosphere mostly because of malcontents like Trump and Congressional Republicans, the answer is we will not be able to and will likely lose more positions in Congress and lose the Presidential election. The sad fact is that the carefully cultivated Republican base is inflamed through hatred and anger rendering them incapable of even recognizing that their leaders are denying them health care. That is the power of psychological messaging.
Get real about health care. As people are so entirely brainwashed against their own well being, it just isn't going to be a winning issue.
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@PATRICK This comment ignores that proposals like Medicare for All poll well across the country, even among Republicans. People aren't so brainwashed that they can't see their money being drained away from them.
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@PATRICK, even with all the propaganda against it, a universal Medicare system enjoys a popular base of support in most polling. The issue isn't just the GOP. Voters see the Democratic Party also caving to industry pressure, and don't see anyone as their advocate -- this is part of the reason we have such a large non-voting population. Perhaps if the Dems courted non-voters more aggressively, we would better political outcomes.
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I agree that the threat of taking away private insurance from employed people is not going to go over well. The best way to go is therefore to introduce Medicare for all in parallel to the existing plans.
When the Medicare expanded system is stable and reliable, many employers will then logically proceed to phase out private base insurance (first no longer for new employees etc.).
Private healthcare insurance companies can limit some of their losses by providing extended coverage, also mostly included in corporate salary packages. Their services can include direct hospital payment, a private hospital room, repatriation services from abroad, or specific treatments/procedures not covered by Medicare. That's the way it is a lot of EU countries.
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Some european national health care plans (NHCPs) give monies directly to people and they spend it for health care. They can buy extra insurance if they want.
Of course we do not need "Medicare for All" in the form we currently have it for seniors. That should be obvious. Frankly as a senior, I have looked carefully at my medicare and if I had a long stay in the hospital, I would go broke in a short time. After a certain number of days, the individual on Medicare must pay the full bill per day; and that is through the roof. My point: most would not want Medicare for All.
You are correct; there are many ways of getting everyone covered and they need to be discussed. It is difficult for me to imagine America being able to do that publicly; people do not like detail; and there is a lot of detail in a national health care system.
We need a leader to start us through a discussion of the various options. Many exist in the world and we need to look at them. Bernie has a website with his plan on it. Let's let every Dem who has a plan, get it up on a website so that everyone can study it. WE NEED THE DISCUSSION YOU WISELY SUGGEST.
Another option to consider for the Democrats goal of realizing and marketing affordable, universal healthcare in this country — a Medicaid buy-in. Open up Medicaid, which currently insures 76 million Americans, to anyone and invest in upgrading this well-established program to meet 21st century evidenced-based standards — salaried providers paid Medicare rates, in a vertically integrated system, that is primary-care-centric, with government setting basic standards managed by private care plans (currently 67%). Allow Medicaid to join our two other social insurance programs, Social Security and Medicare, since private insurance has not been able to solve the cost of affordable healthcare. Medicaid now becomes the de facto public option against which employer sponsored (ESI) and commercial insurance must compete. 80-90% of all health expenditures are incurred by 10-20% of the population, and ever-increasing age, with its expectant infirmities and disabilities, will continue drive costs upwards. Therefore, you could insure a substantial number of Americans for very little cost. By explicitly informing workers how much their healthcare benefits cost and allowing them a Medicaid buy-in choice, you could finally break the monopsony of ESI (which insures 160 million), creating a win-win situation for employers and employees.
Given Republicans' ideas on healthcare and their Medicaid proposals to impose additional entry barriers or to defund it — this should be an easy sell.
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Does Mr. Kaufman’s assertion that people insured through employers are satisfied with their coverage come from the for-profit insurance companies? I am highly skeptical of this claim.
I have been insured through for-profit insurance companies my entire adult life. I hate this system. We pay thousands each month with high deductible policies that “might” cover a portion of a catastrophic illness. We pay for regular care out of pocket.
We are the “fortunate” ones. This system is a sham because it is not designed to provide the best health outcomes; it is designed to provide the most profit.
Universal coverage single payer health insurance is needed.
It is astonishing, in view of the healthcare policies of other advanced countries which recognize human healthcare as a human right, that Americans do not demand Universal Healthcare, Medicare for All! However, Republicans have successfully convinced Americans to vote against their own self-interest for decades. Equally, one would think that corporations, private organizations funding insurance coverage would want out of the healthcare enterprise. Perhaps the Medicare for All could be implemented over time but at least start by enacting the Public Option. The U.S. is increasingly an "Outlier" compared to other advanced nations as to the quality of life issues and suspect in view of the political environment that the disparity of decline will continue.
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What appears to be getting lost in the "Medicare For All" proposal is that Medicare is hardly free. It is, in fact, quite expensive. We pay for it in taxes all our working lives, then pay steep premiums out of our Social Security checks after we retire. On top of that, practically all Medicare recipients pay for additional supplemental coverage which isn't cheap, either.
The best way to achieve universal coverage is to offer a public option and let people who have coverage through their employers keep theirs. Over time, people will most likely choose the cheaper government option and this will minimize private coverage because they cannot compete.
Nobody will lose private insurance over and above those covered by Medicare. Medicare currently allows employers to supplement retiree benefits in order to provide more comprehensive coverage, I know I have such supplemental insurance. There is no reason that Medicare for all cannot do the same.
The way to stop voter hesitation about Medicare for All is to expose these untruths, not to say they might be true.
I never underestimate the capacity of the Democrats (like the Kansas City Chiefs) to snatch defeat from the jaws of victory. The purity codes of the left are as inflexible and punitive as those on the right.
You say that most people are happy with employer provided health insurance. However, to reduce costs, many employers are only offering high deductible plans along with health savings accounts. Satisfaction with this ends when an employee or employee's spouse is pregnant, needs something like heart or back surgery, or needs some other expensive medical procedure. If there isn't enough in the health savings account and the deductible is upwards of $10K, satisfaction with the employer provided insurance declines along with the quality of health care.
Obamacare is, no doubt, better than nothing at all. But we are a long way from a healthcare system that guarantees acceptable health care for all and doesn't break the bank for any.
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Working together to come up with some improvements would be helpful. People care about outcomes, but all politicians can do is screech about philosophy and toss around buzzwords. Socialized medicine, universal coverage, healthcare is a right/not a right, free market, blah blah blah. People want to have preventive care that is affordable. People want to have drugs that are affordable. People want to have medical treatments that are affordable. And our healthcare system needs to control costs to be sustainable. Too many companies have been making a very fat profit off the status quo for a long time. Too many elected officials have been enjoying huge donations and porky perks from those industries. Too little effort has gone into finding ways to streamline healthcare and make it more efficient. It's all about finding new sources of profit. We all get the bill. Time for change.
Understanding how U.S.institutions function and fail in their ostensible mission is not rocket surgery.
It's Racket Science.
That's what I call my lifelong inquiry into the dysfunctions that affect human organizations from families to entire cultures.
Though root cause analyses are superficially variable, a common enabling factor is the often deliberate failure of leaders to accurately clarify the distinctions between wants vs. needs and reality vs. illusions.
That is the foundation of the manipulative deceptions upon which rackets are built. They often persist until hubris drives abuse to excess, exposure and failure.
A minority of the public will always catch on quickly and avoid or out maneuver the rackets.
Unfortunately, that leaves far too many others to suffer the consequences of their trust in the unworthy.
Professor Krugman is correct. Our national health care plan must allow people to keep their private health insurance if they want--although part me says I would love to see Jamie Dimon on the same health care plan as the rest of us. But let people choose; people like to have a choice.
The way this whole universal health insurance need is being approached is wrong--too much hyperbole on both sides, shoving the issue into an either-or rigid and partisan solution.
We have to get back to the American can-do spirit. So many other nations are way ahead of us now in that approach.
First, we need to survey countries with effective health insurance coverage. TR Reid wrote a readable book "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care"(2009). The book may now be dated, but the spirit of the "quest" was informative.
Reid used the example of one Asian nation without national health care that pragmatically went about identifying the best systems ("best" as defined by the subtitle), studied these countries' plans, then visited the nations with the plans that looked most promising for this particular Asian country.
Finally after this research, the country came up with its own plan that appeared to best fit the economic, social, medical, and cultural values and practices of the country. They knew they would be modifying the plan once launched.
However, this "quest" was carried out in a spirit of cooperation--no GOP involved in sabotage
Even if we do go to something akin to the UK's NHS, which is true socialized medicine, it's worth noting that they do still have a private insurance system that functions alongside the NHS. It's apparently a decent supplement for some things, but this private insurance does not outperform the NHS in all or most things.
It would be ever so nice if we could actually discuss the merits of policy instead of simply having one side yell "Socialism!" and call it a day.
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employer sponsored plans are not without problems. Co pays deductibles and premiums rise drastically each year challenging even the most empathic employers to keep up. They are forced to pass on some increases to employees however they aren't able to increase wages to help employees pay. I've got nothing against private insurance but I never see any proposals from them which makes me suspicious.
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Totally eliminating such a well funded entrenched "industry" as the private health insurance biz as a part of "medicare for all" hasn't a snow ball's chance in Hades of passing even if the Democrats take back the senate. I was not aware that any adults thought otherwise. Should we have national healthcare in this country? Absolutely yes. Should employers be relieved of the absurd burden of providing it? Yes, of course. But, there is no way we get out from under the private health insurance lobby while Citizens United remains law, and the supreme court is in the hands of the right. A hybrid system is the best we can hope for until a lot of things change that the election of 2020 will not directly effect.
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The summit is universal healthcare, and Democrats need to keep in mind there is more than one path to reaching the summit. As a former board member of a state ACA exchange and a communications professional, I have tracked ACA public opinion for years. It was only about a year ago that a majority of Americans supported ACA after years of a stark public opinion divide. It makes far more sense to build on the law, extending a Medicare option than to start from scratch. Health industry lobbyists are mobilizing a campaign against "Medicare for All" with rare unanimity among healthcare players. Public support for Medicare for All drops to the 30s when you say people will lose private insurance plans. When ACA has finally turned a corner, do we really need this fight? Medicare for America is a far more sensible approach to that elusive summit of universal healthcare.
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There is no equivilancy between Sanders and the rest of the field. He is a fraud. Krugman helps him look less so here, possibly because he may be more committed to manipulating disciuree than telling the truth. He wants the far left to back off without bogging it down against the more united Right.
There’s a problem. Sanders really is wrong. And Krugman knows it
Take a few of Krugman’s points.
Australian medicare incurs significant out of pocket costs on its users. It also is heavily means tested, richer Australians are penalized for using it and are encouraged to buy private insurance to create multiple pools. Sanders is opposed to these strategies in principle. Australia also maintains a large public hospital system and heavily regulates graduate physicians to bring them under the wing of the state. All of this information is easily available on the internet or if you either talk to Aussies or go to Oz (Krugman was recently there.)
UK healthcare is also different in ways not highlighted by Krugman, which should affect our take on Sanders, but he knows it. The NHS doesn’t just give everyone coverage. It micromanages almost every aspect of healthcare including employment and facilities. Sanders has no plan for accomplishing his version of universal coverage without universal management.
There is no precedence for what Sanders proposes to do with American healthcare. There is no reason to just trust that it will work.
He’s a fraud. Krugman knows that.
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TR Reid's 2009 survey of healthcare systems of a number of industrialized countries provides a first-hand look at a variety of ways these systems are structured and how well they work. There is no shortage of models, and they pretty much all work better than ours, which amounts to rationing of health services based on your employment and wealth status. France is another example of a system that includes insurance companies - who are then closely regulated and abide by standards to head off the kinds of appalling failures and ripoffs we read about (or experience) daily in this country. While Medicare for All is something I would happily participate in and believe is a noble aspiration that might even work, let's start here: an option for anyone who wants it. Sign me up.
1
Debate notwithstanding likely the Bismarck system is the best for our nation.
This is the system used by Germany, France and most advanced western nations. It is simple.
Government defines healthcare; universal coverage, the services mandated and pricing. Then private suppliers including insurance companies compete - what a concept - to provide healthcare to the market.
Those private suppliers can include employment based insurance programs, independent clinics or whatever fits the market demand, essentially what we have today.
This is government definition and oversight of healthcare. Or as Sara Palin might call it a system of 'death panels'. Everything operates under the government umbrella so there is no unconstrained cowboy profiteering.
This all works quite well with better results and lower costs than we have. It is also easy to design and implement given the current framework we use.
The difficult part is getting past the greed and larceny of the players in our healthcare stumble bumble system and the influence of the plutocrats.
Then again that defines many if not most of our current problems.
2
Exactly. I am hoping for an enlightened debate, not the spectacle we witnessed in 2016. No doubt that insurance is the wrong paradigm for healthcare. And unlike broccoli healthcare is not a lifestyle choice (a fact obvious to most with the exception of a certain Supreme Court Justice and the solicitor general tasked with convincing him). No doubt in a perfect world everyone and every condition would be covered. If Medicare For All is the best approximation to that it will be up to Sanders and Warren to sell the voters on that.
Paraphrasing the words of Admiral Ackbar, the Healthcare issue (and inevitable debate) is a trap for Democrats in 2020.
The coming debate over what Medicare for All may or may not mean gives the GOP all they need for an unending bombardment of Dems as advocating [gasp] SOCIALISM!!
There are no easy solutions regarding healthcare in the US and our problems extend well beyond health insurance coverage. One example: the US has far fewer doctors than most developed countries (we are 52nd on the list, behind every Eurozone, NATO and G7 country.) Compounding that, the US has fewer GPs and a much higher proportion of specialists than other countries. Yet you almost never hear a discussion on this important healthcare topic.
A bruising fight among Democrats regarding Medicare for All will only ensure both continuing GOP control of the Senate and that there is no change to the current occupant of the White House.
Dems should instead focus on the GOP's abject failure to remove the ACA and replace it with, as President Trump so elegantly put it, "something really terrific."
3
Saw a 60 minutes or 20/20 episode about the variety of ways other countries did universal health care. All had plusses and minuses but all seemed to cover more folks and offer better care than what US has.
1
Here is why it is a purity test:
Insurance & Pharmaceutical PAY our politicians to keep universal coverage from being a right of all Americans. They know it is only a matter of time so they are now raising every fee and charge they can to store in their off-shore accounts.
The trouble with our whole democracy is the wide-range corruption created by these political "donations".
Standing up for Americans in the fight for Universal Healthcare is the first step to showing that the politician will NOT be BOUGHT AND PAID for by special interests and corporations but will instead be focused on WE THE PEOPLE.
3
So long as Bernie is still campaigning, he’s going to introduce arbitrary litmus tests to the debate — and attack the integrity of anyone who tries scoring his proposals and calculating their costs.
3
"Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change."
And it looks like Paul Krugman, just from the way he makes this statement, thinks it's not only inevitable but a horrible loser of a stance to take. I think he's wrong. I think we can win this battle of ideas and convince work-insured Americans that there are far better ways for them to receive health care benefits. Ways that are working in many different countries delivering better results for far less.
Democrats should not be peddling Republicanism light, as he suggests, but progressivism strong, as in Bernie Sanders, Elizabeth Warren or Tulsi Gabbard.
Whoever the Democrats nominate should stand strongly for policies that will reduce inequality, strengthen the social safety net and take strong, immediate action on climate change.
Now there's a winner if we can just get it past the wall of corporate shills who will go to the mat to keep the public from getting an opportunity to vote in those principles.
Leaving private insurance works only with heavy regulation. That means standing up to the insurance lobby. Good luck.
3
As per Dr Krugman - Democrats must come to agree on goals and then debate respectfully how we get there. The progressive movement within the party is still forming so if idealogical purity concerning process is broached the question should become whose ideology? Progressives should be careful - since some in our current crop of presidential candidates maybe more interested in self promotion than leadership. Here's hoping we continue to move forward, united around big goals, rather than forming a circular firing squad.
The first graf:
"We’re now in the silly season of the Democratic primary — a season that, I worry, may last all the way to the nomination. There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability. It’s a discussion in which essentially nobody has any idea what he or she is talking about."
This may be the best political commentary all the way through the 2020 post-election hind-sighting.
Thank you, Mr. Krugman.
I had spent several years as a consultant to the health insurance industry, and its complexity is correspondingly matched by misconceptions of it, such as:
- most large companies are self-insured, meaning insurance co’s are in fact low fee administrators - not insurers - to a large swath of the population
- many insurance companies are non-profits, eg most blue cross plans (tho largest BCBSs are now for profit)
- over one third - and rapidly growing - of Medicare recipients subscribe to private plans - ie private insur company ppo’s and hmo’s
- high prices often are driven by providers - not insurance co’s - who in many towns and cities have consolidated to the point they control access to and price of care.
Medicare for All doesn’t acknowledge these realities or the fact that sensible changes to the ACA could ameliorate many challenges to access and cost. Plus, if we were to have single payer, what happens in times of budget overruns? ... Medicare for all turns our system into a political football. Thus It isn’t a panacea many think.
The ACA was imperfect but a huge step in the right direction ... We can have a better system by improving upon what this started.
I've been a proponent of "European socialism" for most of my adult life. Living in the Netherlands for a number of years will do that to you. Ordinarily, my beliefs are well to the left of the Democratic party. In this case however, I side with Krugman. The goal is not to take down health insurance companies (although I do welcome their hatred). The goal is to do something--anything--to make significant improvements to the hot mess sometimes referred to as "health care".
Unfortunately, concerns such as "what will happen to the enormous health industry" are not without substance. Going from zero to 100 and doing away with all private insurance in one fell swoop? Quite a task, particularly given our general inability to accomplish much of anything.
A better approach would be to leave private insurance alone while offering a Medicare buy-in for ages 55-65 and 18-30. 55-65 for those who need it most, and 18-30, since that group often carries no insurance AND to hold costs down. If--big if--this could be accomplished along with at least some cost controls and administrative savings, the public option might prove more and more attractive to those, now privately insured who are "happy with their insurance". Or--they and their insurers continue to be happy, as well as the formerly uninsured or under-insured now enrolled in Medicare. Or...an improved Medicare becomes so appealing that private insurance simply withers and dies. Either outcome seems fine to me.
1
The Democratic Party apparently is in the process of redefining its mainstream in the direction of more activist stances to deal with issues of prejudice, inequality and climate change. It's a process that's necessary if the Democrats are going to be more than a variant of "more or less sane moderate Republicans", which too often they've been under Bill Clinton and, to a lesser degree, under Barack Obama. The sort of purity tests that worry Dr. Krugman are, I think, a normal part of the arguments that go with this redefinition. Fortunately, I believe that this process will involve a lot of name-calling and apparent allergic reactions that will heal to a great degree in the run up to the election. I don't mean to be dismissive of lack of toleration, but I do believe that it's necessary to take a lot of the current purity rhetoric in the spirit of vigorous debate involving people whose emotions are strongly engaged.
Purity, no. Decent policies that actually help working people. A must. Don't make false unity a choice. If you really want to unite, then unite under the policies everyone is in favor of.
As a number of comments mention, private for-profit health insurance has one goal, to maximize profit for the insurance company. They do that by denying care, which is easy, and by reducing cost, which is more difficult.
The inability of the Democrats to explain this to those opposed to Government Health Insurance (aside from those who profit from the current system, which includes many politicians) is a shame.
3
I’m progressive, have worked in the health-care industry and been a life-long critic of the bizarre and wasteful way we deliver medical care. The AHA was a seminal achievement IMO. It should be robustly shored up, including a public option. Medicare for all is a much too radical offer, given it’s upfront expense and dislocation to those satisfied with their private coverage. More importantly, it would be mercilessly attacked as “socialism” and this message would likely resonate to the Democratic Party’s distinct disadvantage.
3
The only way for these proposals to succeed would be to sharply reduce the fees that are being paid to physicians and hospitals. Many doctors have already refused to take Medicare patients because of the reimbursement schedule.
I worry about how the overhaul of the healthcare system is being treated with such simplistic naive easy peasy bumper sticker type statements. All of the countries cited we should follow have a mere fraction of the population that we have. Denmark has 5 million people, roughly the size of Brooklyn. Even England and Canada have less than a quarter of our population. Many seem to be blaming the insurance companies when doctors aren't in their Network. Actually, unless the doctor is completely incompetent it is the doctor who is choosing to leave networks because of reimbursement. Do we think that these doctors are magically going to jump at hugely reduced fees that they will get under MediCare for all? The last person who really tried to pull together experts from all fields and try to come up with meaningful Solutions was Hillary Clinton during her husband's administration. I worry that with the slogans and bumper stickers we are simplifying the problem to the point of irrelevance.
@CLSW2000
Those who have put money over a man’s health should be ridden out of town.
If Medicare is an option that people pay into (so it is not an entitlement) and private insurance is kept in place so we don't end up laying off millions of Americans who work in that field, it will be a much easier sell
1
Here we go again, a push for Obamacare II, that will appease the centrists in the Democratic Party (akaRepublican Lite)and their mega donors in the insurance(Hello Joe Lieberma. Obamacare/ Medicare is not a panacea in its current form because as long as there is private insurance the Doctors hate it for the simple reason they are being paid less for Medicare patients even with a supplement than for those not on Medicare with private insurance and there is no conversation about this until you as a senior find out for yourself as you are shuffled of to Nurse Practioners or tech school graduates. I have been a resident of a Southern Oregon coastal community for four years and have yet to get a G.P., rather you are directed to Urgent Care where you wait around for hours to be seen by a N.P., I and my significant other were at one such facility in North Bend Tuesday, we signed in at 11:00 saw a nurse at 1:00 waited another hour for a N.P. to examin3 us an issue a prescription for antibiotics and another med to fight off a severe strain of bronchitis that seems to have arrived in our fair hamlet, total time to get a few pills that are available over the counter in some European countries, four and a half hours, so tell me how great a Medicare is. Single payer and a lot more physicians are needed and since we aren’t producing them we need to loosen up immigration for Indian Physicians not just allow cheap labor to arrive across the border at will.
1
@Ted Reason we have a Doctor shortage, particularly in rural areas, young people are going into finance and tech where the big bucks are and the cost of all education is obscene, but when you consider the years needed to become an M.D. at a huge cost and the uncertain future young doctors face with no clear direction of what system they will have to work within you can’t blamr them when their option might be a stint with Goldman Sachs or catching the gold ring in Silicon Valley for working on some inane little app and you’re set for life, it’s a goofy world with all the wrong people being rewarded, until our health care givers are at the top of the food chain again we can expect worse and worse care, they must make decisions that are best for them and their families as well, and who would choose eight to twelve years of college hundreds of thousands of debt when you can walk through the right door in Oal Alto with little talent and end up very rich.
2
Medicare is a single-payer system, supplemented by private insurance. That’s how all single-payer sustems work.
My one item is voting rights. If a Dem President with s 2-year Dem majority in Congress does nothing else-this is the one thing they must do-restore section five of the Voting Rights Act. Everything else I want is not achievable without balanced electoral laws.
1
An editorial yesterday admonished Democrats to avoid complex policy proposals. Most voters won't take the time to understand complicated arguments. The Affordable Care Act was actually a case in point: too complicated for most Americans to understand. It took years for people to begin to realize that it was better than what they had, or didn't have, prior to its implementation. The constant drumbeat of propaganda against it from the right didn't help, of course.
The case for Medicare for All (or better, Medicare for America--making it an option) is that, while complicated, most American voters have already become comfortable with the notion of Medicare for the elderly. It is not some new, scary commie proposal from the radical left. It took decades for a majority of Americans to realize that it wasn't really the "end of freedom as we know it" as Reagan claimed.
What's more, it already works for millions of Americans, and (this is something I never see mentioned) it already covers many of the people who are entering, or are in the most medically expensive period of their lives. Adding younger, more healthy groups to Medicare should actually make it more affordable.
In other words, the heavy lifting of selling a Medicare-like solution to health care has already been done. The far right has failed to demonize it as the end of freedom.
The simplest way to achieve universal care is offer a public option, just as Obama proposed years ago. It wouldn't take long after that, and politicians could find something else to argue about.
2
"A Medicare for All plan would in effect say to these people, 'We’re going to take away your current plan, but trust us-'"
The jury is out on what Medicare for All will "in effect say" to people with company healthcare - maybe it will say, 'We're going to free you from a dependence on crummy job whose insurance you are 'fairly' satisfied with only because it's better than nothing.'
You don't know how those insured will respond as they are get more information.
3
There's some truth to skepticism over private interests. Obamacare would look a lot more like the Netherlands if medical and insurance lobbyists hadn't gotten involved. Moreover, Obamacare would look a whole lot more like the Netherlands if Democrats hadn't wasted time trying to appease partisans who would ultimately vote against the law anyway and then go on to support its destruction.
We don't need a purity test. However, as we've learned in the recent past, taking qualified positions on core principles leads to compromised outcomes. I don't use the word "compromise" politely either. We wouldn't need to have this debate if Democrats had just done it right the first time. They lost really bad in 2010 anyway. How much worse could things have gotten if a 51 vote Senate majority had just adopted single-payer way back then? We'd already be enjoying our non-employer based health care by now.
By the way, employer based health care is terrible. Even when you have good care, not very common these days, you are still beholden to the employer. I can't think of a bigger threat to labor than holding their family's health hostage to an employee's work productivity, There is no one born in the past half century who can legitimately defend employer based health insurance.
3
A 51-vote majority did not have the power to invoke cloture at the time. And during the ten months Democrats had 60 vites, they were kinda busy with the economic collapse they’d been handed.
As usual Krugman's acumen raises important political position issues central to the Dem's ability to win the next Presidential race as well as flip the Senate by 2020. A smarter solution than trying to predict which position on health insurance will be more appealing to the voters is to focus on Elizabeth Warren's appeal for a Constitutional amendment to eliminate the Electoral College in time for the next election. Many blue states are already in the process of making real change to the way the votes are counted which will truly mean one person one vote instead of the candidates spending all their time & energy trying to win over specific voters in the Rust Belt states that Trump was able to flip through chicanery, outright lies & help from Russian bots. Why should Democratic candidates focus on charming voters from Wisconsin, Michigan, Ohio, FLorida, Iowa & Indiana when they don't represent the collective country, just to ensure winning the Electoral College? Personally I side with Bernie's Medicare for All position which grants the government the power to negotiate lower prescription drug pricing & the power of the government to manage lower overall costs better than profit based insurance companies. As long as health care is profit oriented business without cost cutting & patient protection regulations then there will continue to be problems. Without having to battle the GOP propaganda & fear mongering political machine, Dems can pick the right policy for all people.
1
What medical system should we implement?
Well... the one that can survive a Senate filibuster, an onslaught of insurance lobbying money and opposition, Democratic turncoats and opportunists in the Joe Lieberman mold, 24-7 right wing media opposition and falsehoods, ferocious opposition by hugely uninformed political blocs (Tea Party 2020?), and a press corps without the expertise, nuance, or judgment not to equate increased health subsidies to death panels.
What system is that? It's status quo, just like the insurance companies like.
3
It's worth pointing out that in the UK, in addition to the "socialised" (uniquely an American descriptor for universal coverage) system managed by the government (the NHS), there is a buoyant private health system running in parallel. Consumers pay insurance premiums to private companies and receive care in privately run clinics and hospitals. Some of these premiums are paid by employers. That said, these consumers receive no tax relief on the premiums they pay so they are in effect paying twice: once through their general taxation which pays for the NHS and again through their private insurance premiums.
Medicare For All, or For Most, or For Whomever Chooses It, represents a reform on the demand side and will (if it works as desired) result in more people using more medical services.
The cost controls associated with Medicare-type plans seem to revolve around paying hospitals, doctors and pharmaceutical companies much less.
Meanwhile, proposals for reforms on the health care delivery side are lacking.
Even an economist afraid of telling the truth to his own readers can predict the result: provider shortages and longer wait times.
Wait times in Canada are a problem. 26 weeks is the government standard for a hip replacement; Canadian doctors would prefer a 13 week standard. The median achieved result in 2017 was 27.5 weeks (provincial range of 18-52).
Of course, a Canadian with money comes to the US to cut the line. Not clear where an American would go but medical tourism is on the rise.
https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2017
1
At a time when every pundit making over $500 a week is on red alert over socialism in the United States, I think it's funny that Dr. Krugman mentioned the Netherlands in this piece. The Netherlands is nation that has long prospered by using principles and practices of capitalism in business and finance. Yet successful Dutch infrastructure and social programs, including health care, are a tribute to what many blinkered people in this country sneer at as "Socialism!" Let's stop sneering at people who do things right and try to learn from them. Here's a brief example of a quick learner. http://www.technoccult.net/2009/05/10/the-netherlands-paradox-capitalism-and-socialism/
4
Yes, any comprehensive system would be vastly better than the present one. But, I get so tired of the justification/excuse that almost half of us receive health insurance thru work. The reality is that the majority DO NOT get work health insurance!
Further, the one plan that receives approval is Medicare. How many of us sigh in relief on reaching 65? I suspect us all. No more worrying about losing a job and thus health insurance, no more planning career moves and where we live based on keeping our work health insurance.
Just imagine being able to act independently without the worry of losing your or your family’s health insurance ? (Most of us can’t.)
And, given an automatic 15% savings off the top from overhead reductions between private insurance thru work or otherwise (20%) and Medicare (5%), it’s hard to keep hearing its unaffordable.
It’s not just private insurance, it’s that every component is designed to be protected from competition and ensure capitalism for the businesses to the detriment and real harm unto death for us......the customers.
6
As usual, Mr. Krugman is right. Look at what the Republicans and Trump who seem to believe that the interests of the insurance companies, drug manufacturers, and others who make huge profits on our private system take precedent over the well being of those requiring healthcare, have done to Obamacare. They would almost certainly bastardize any Medicare for all effort if it could actually be enacted. And, of course, they are just waiting to pull out the 'SOCIALISM' card during any election where a Democrat might say anything that even sounds as if someone might lose their private plan.
As for me, I have been on Medicare now for the last five years after having had private employer based plans for most of the time before that and a few years in the individual market as I was self-employed. Medicare is the best that I have experienced and I definitely would not want to go back.
1
"Britain has true socialized medicine — direct government provision of health care." This should not be read as there are no alternatives to a resident's particiption in the country's NHS. There were private health care alternatives when I resided in the UK 30 years ago, normally funded by an employer as a "fringe benefit". One was "BUPA" (British United Provident Association, a private health insurance organization), which was used by my employer. It still exists today. No one has to relinquish his private plan if he (or his employer) doesn't want to. It is interesting that despite this,
private insurance company funded alternative, less than 10% of health care is handled privately in the UK, which corresponds to the almost 90% satisfaction of those utilizing the NHS services.
6
Professor Krugman says:
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
First of all, what is so wonderful about our current employment-based plans? And what does it mean to say that most people are satisfied with their current plans?
Is it that "people like them" or they are simply used to them?
Our current plans are based on refusal of coverage, denying pre-existing conditions, and a lack of portability. Our employer can have added power over our jobs by a fear of loss of coverage if we lose our job.
What are we concerned about in health care? Why even have this discussion. It's because of concerns with pre-existing conditions, bankruptcy due to a lack of coverage or an expensive procedure, portability, lifetime limits, and fighting with the bureaucracy about what whether we are covered or not covered on individual procedures or events. And cost. Cost would be reduced by Medicare-for-all if bureaucracy costs were cut.
Doesn't it make sense to offer alternatives to the current system? Why even worry about this change, if it is simply about fixing the limitations mentioned above and staying with the same system?
2
I support a medicare for all system. Medicare should be paid for through excise taxes. If you smoke, drink, eat a lot of sugar, you are entitled to do so, but the probability increases that you will be the one using the medical resources we have. Many Americans have an unhealthy lifestyle. Order a soda in Europe and you get a little glass, not a super big gulp. Those are choices that we should be entitled to make with our free will. However, those who live a lifestyle that will drive up the healthcare costs in a one payer system, should pay their fair share somehow.
2
There will be no Health Care Reform if Trump is re-elected.
He campaigned on Health Care Reform, telling us he already had a plan for reform. “Repeal and Replace”. Yet even with a Republican majority in both Houses, he couldn’t or wouldn’t deliver on this promise. He pushed his Republican Senate to pass a last minute rush job “Repeal” with no real “Replace”. And couldn’t deliver.
So the first goal has to be “Repeal and Replace” Trump.
To do that, candidates must look at the electorate and determine how to meet their needs and wants. Many Americans seem content with employer-supported health insurance. Unless candidates can convince the electorate BEFORE the election to support a plan that doesn’t incorporate what Americans want, the candidate won’t get elected.
So, yes, ideally one idea may make the most sense. But in reality if people don’t support it, it won’t happen.
FDR pushed through Social Security when the nation was in the throes of the Great Depression. LBJ had a solid Democratic majority in Congress.
Candidate X will be confronting a divided America and Congress. The worst thing would be to divide the country eve further.
4
I support Medicare for All because after careful consideration of every possible policy, I think this one has the best chance of passing without triggering a recession. The bill has generous work ins for phasing out insurance employees and will simplify the process of actually giving healthcare from the provider's prospective. It's the least likely to trigger a supreme court case and the most likely to actually be accepted by the AMA. I'll support whoever our nominee is, but I'll fight tooth and nail to make sure they don't make a mistake and pass a watered down version that robs Medicare For All of the cost saving based funds it would require to be implemented.
Dr. Krugman, I see you are still hanging on for dear life to your failed neoliberal solutions to problems caused by that very neoliberalism. I have been a physician for almost 40 years, and have seen first hand the folly of repeated market- based solutions to the problems of the uninsured and underinsured. I have seen at least 5 or 6 "radical" changes in healthcare reimbursement, and we remain the only developed country in the world where the uninsured and even the insured go bankrupt due to a disease or injury. This failed system has also resulted in our outcomes being outside the top 30 countries in spite of per capita expenses being 50% higher than that of any other country. What will it take for the so-called pragmatic moderates to determine that our badly failed system is well beyond incremental improvements saving the thousands killed annually by our dysfunctional capitalist healthcare system? A Nobel prize winning economist should know better. On the other hand, perhaps your lack of understanding of our problem reflect a deficit in the science of economics itself?
1
I’m from the UK, and I’m happy with the system we have, despite massive inefficiencies & waiting times. But I do think a two-tier system with private insurance, like in The Netherlands, Germany and Australia would be better. Universal coverage is the end goal, we need to find the most efficient and equitable means of getting there. It would be polite, good mannered and true if you did not to accuse anyone who views markets as useful to be neoliberal.
1
"Medicare for America" done right, could eventually morph into Medicare-For-All. And, if not, it could surely make the parasitic private health insurers a lot more effective and efficient by providing them with serious head-to-head competition.
2
I will not vote for any candidate that doesn't support true universal healthcare. The insurance companies themselves are one of the primary reasons health care has become wholly unaffordable. And as Obamacare has proven, many people are still left out of a system that relies on subsidies to offset the cost of health insurance for the poor. I happen to be one of them. Since I lost my private insurance in 2014 (it was an individual plan I could not afford to keep), I have been without. Even with subsidies, I would have been asked to pay over $200 a month for a plan that would still leave me forced to file for bankruptcy if I ever got seriously sick or injured because I would have no way to cover the thousands of dollars that would still be my responsibility
The current system is 100% broken, 100% rotten and corrupt down to its core, and anything built on the existing foundation will be 100% doomed to fail.
3
Along with Bernie Sander's proposal for Universal Healthcare, which will certainly aid all the US citizenry,, comes his promise to control the banks and their executives, who received huge bonuses after bringing down the economy in '08 (!), free tuition in state colleges, and a $15 minimum wage.
Bernie has advocated these measures for years. He hasn't adopted them to follow a recent trend, as many have done, and can be counted upon to see them through.
1
The annual average deducible for employer sponsored health plans has risen 5X in the last ten years. Paying thousands of dollars a year for coverage to groups that include do-nothing profiteers is frowned on by a great majority of the public. Bernie Sanders MFA would allow those who want supplemental care through private insurance the option to do so. What's so bad about that?
3
With any change, there will be hiccups but I simply don't know one employer who will raise salaries if they no longer have to pay for employee healthcare. This will not happen. working on the administrative side for small and medium firms, I have seen premiums triple and coverage and deductibles rise over 15 years. Employees have been forced to pay for more of their premiums knowing you have no certainty beyond the next 12 months of coverage. This is no way to live. Change will hurt but employer based coverage needs to be abolished, just do not count on employees ever seeing that money again.
2
Krugman is of the opinion that the half of our population that is covered by employer based health insurance are generally happy with it. I have my doubts, but think what they are primarily happy about is the fact that they are fortunate to have health insurance at all. I wonder what the other half who do not have health insurance supplemented by their employer, or are without any insurance, think about the issue. And it would be useful if Krugman addressed which proposed plan best addresses the runaway cost of medications, a key aspect of any plan.
1
Insistence on purity would be a mistake on each and every issue. We all need to be willing to make compromises to move forward as a group. And calls for purity are a regular source for infighting and division (I have seen this happen, often, on the left).
Our strength as Democrats is in our cohesion and mutual support, even if we may disagree about particulars. We will rise together or we will fall apart.
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@Duane McPherson
We might disagree about particulars, but I'm concerned about the agenda in this column. In 2016, Mr. Krugman referred to Bernie Sanders' "Medicare for All" proposal as "rainbows and unicorns". It seems that, while Mr. Krugman's views may have moved with the times, he is still - perhaps - protecting the business model of Corporate Healthcare.
3
@Duane McPherson I think the point of this article is that whatever proposal is agreed on must be sold to people easily taken in by fox news and company, who are already screaming about (gasp) "socialism" and using Venezuela as an example. (My personal view is that Venezuela's main problems are corruption and stupidity, which can be more easily compared with the current US administration.)
13
@Ellen: The attitude with which you write your comment is exactly the "purity" that Krugman is referring to. Krugman's agenda isn't to protect the business model of Corporate Healthcare. He's simply giving his point of view that 156 million people may be satisfied with their health insurance and perhaps Medicare for All is quixotic--and Medicare for America may be a more politically palatable proposal. I am a Democrat. But I find that my fellow Democrats can be intolerant of the opinions of others in our party. Keep this up and we're sure to have four more years of the orangutan
21
The biggest advantage of socialized medicine is that it would give someone in power an incentive to reduce overall medical risk through high-efficiency broad-based illness prevention.
It's still true that an ounce of prevention is worth a pound of cure.
Redistributing medical resources toward the front end (maintaining health in well people) has enormous economic, moral, and emotional benefits over high-intensity efforts to bail out the severely ill at the last possible moment before death or permanent disability.
The latter are necessary too, of course. But a system based around last-ditch effort is a bad system. A system in which poor people are guaranteed emergency care, but not routine health management is a bad system.
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@James with all due respect, as a person that delivers healthcare, “prevention is worth a ton of cure” is a great slogan and absolutely correct in the ideal, but in the real world, doesn’t pan out. The reality is that many people choose not to engage with the healthcare system until something bad happens. Many people only use medical services in times of emergency. The Oregon experience with the ACA confirms that. Even with adequate medical coverage, many people still used emergency services as their primary contact with the healthcare system. At its essence, preventative care is based on convincing an otherwise asymptomatic person to engage with the healthcare system to manage issues that may one day lead to significant morbidity and mortality. Preventative care, in itself, requires a commitment to enduring the minor inconveniences and discomfort of engaging with a healthcare provider and following recommendations to achieve a long term goal. In my experience, the biggest champions of preventative care are those with means and education who see it as a means to achieve greater quality and quantity of life. They assume that their own opinions must be shared by those at different socioeconomic and education levels and thus incorrectly assume that if the means are provided for preventative care, everyone will partake. That is incorrect. Interventions that might make overall health better among the rich and educated may have no bearing on everyone else.
8
Only theoretically. There are many incentives that insures have but they pale compared to profit. The main incentive for people in power is to stay in power. That is the main value of democracy.
There are many ways to incentivize health care recognizing the point below that the financing shouldn’t focus on annual or quarterly results but the long term. It’s hard to imagine the government being able to do it with annual budgets and budget fights. Finding solutions that don’t have the government running a $3 trillion dollars a year industry, that makes people less dependent on their employer, emphasize preventive care, protects everyone seeking care to avoid bankruptcy, and is able to meet the needs of the booming older population is the key. There are many ideas that can accomplish that without government involvement in every health care decision. Anything that does that will put Republicans in power. We can not afford that now more than ever. Simplistic solutions that carry anger and emotion will reinforce the view of liberal Democrats that will, even if Trumps defeated, will be short lived. It’s happened before and will happen again.
@James spot on. In The Netherlands the patients re forced to regularly go for checkups. Any decent system builds that in.
8
I'm retired. I'm on Medicare. Funny thing is that I and everybody that I know who is on Medicare loves it.
If they are on the Left, they'll say "I deserve it and it's about time" and if they are on the Right, they'll say, "I earned it."
Just make Medicare an option and quickly, people will learn that those employer plans with their super high deductibles are not all that great.
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@billd
I am on Medicare too. And I love it as well.
But when you say Medicare for All. And "we have to get rid of private insurance plans," it scares people. And they would instinctively say, "We can't afford it; I don't want to pay the very, very high tax to provide to all." They would rationalize it by the thought that Medicare was introduced to help out very many retired old people who couldn't afford to buy private health insurance. It doesn't matter, other developed countries have it at much less cost.
So we should start with a Public Option, which is doable. Eventually, Medicare for All will be evolved from that. The opposition to such a plan will be much less.
37
@billd I am on Medicare too and I love it. But I also have a Medicare Supplement Plan subsidized by my my employer. So Physicians know that my deductibles and Co insurances will be paid. Will those without supplemental plans be required to pay up front or will offices have to spend an enormous amount of time chasing down what they owe. Or will Medicare for all do away with the deductibles and coinsurances? And if we do that who will pay for that to happen? Oh yes, the rich!! And how many years will it take for medicare-for-all to be cost-effective? and during the huge upheaval in gargantuan taxes that are going to be needed for all will Republicans sweep all three branches do away with whole thing?
5
@billd
Medicare doesn't cover all your medical expenses, isn't it right? Do you pay for supplemental coverage?
That should be a blueprint for "Medicare For All", where this program has very high deductible, let's say 50K, which will be covered by private insurances pretty much the same way it's happening now - purchased by employers or individually. But these policies will be relatively inexpensive because they need to cover only up to 50K. People will still be dealing with their insurance companies, the same way they do it now, with the difference that the insurance company will send the bills exceeding their coverage to Medicare.
Yes, we (individuals and companies) will need to pay higher taxes, but the total amount of money that is required to be spent on health coverage of the nation will not be higher - we already pay for it somehow through multiple channels including current Medicare, VA and medicaid that will be covering now the same 50K that are not covered by new Medicare.
3
Paul, you are my mentor on all matters economic. But here's my question: Why can't we offer both private and public plans and allow the public to decide over several years experience?
At the end of the period, we can determine whether to continue with one of both plans. It's not like insurance companies won't have to make changes regardless.
Employers seem less and less committed to full, high quality health care. Shouldn't employees be free to choose which plan they prefer after they can make detailed educated choice? If employers which to attract candidates why can't they offer either health care or pay the equivalence.
3
Yes..."Britain has true socialized medicine — direct government provision of health care."
However we also have a thriving private health care market either funded by private insurance plans, employer schemes through insurance companies, or one off payments, often to reduce waiting times for elective surgery. If you go private you still pay all the taxes that support the National Health Service. You can't opt out of the NHS.
There is also a range of treatments generally not available on the NHS and dentistry is creeping closer to a private service due to a shortage of NHS provision.
So there is a bolt on luxury option if you can afford it. Our education system works in a similar way.
That's socialism UK style.
2
One of the problems that Progressives will have in selling Medicare for All is that they have made a compelling case for the utter corruptibility of politicians due to money in politics. The GOP over the years has made a much less honest but electorial effective case that "liberal elites" cannot be trusted. And Trump has demonstrated the weaknesses in oversight, check and balances, and the value of facts in our system of government in the face of extreme partisanship and the conservative media ecosystem.
So how do you convince the rightfully skeptical, currently insured but potentially persuadable, to let OUR Federal government take this much control over health care NOW?
Explaining all the positives of Medicare for All is easy relative to the challenge of explaining how THIS government, that will without question still be highly partisan in 2020 and still awash in big donor money, is capable of pulling this off.
Have a robust debate. If Medicare for All resonates with a solid majority of voters across a majority of states that's great. I hope it goes that way.
But if not, keep in mind that our democracy may not survive another 4 years of Trump and McConnell. Medicare for All is not the hill to die on.
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@LT, the advantage of a Medicare for All system is that it removes a massive source of corruption within the system. e.g. all the money that goes into lobbying and campaign contributions gets sucked out via the Expanded and Improved Medicare Act. Of course the industry groups are already mobilizing in order to keep the tap of consumer and taxpayer funds flowing to them. However, if enacted, one of the virtues of an actual public insurance system is that it would cut the tap off for a major source of lobbying and campaign funding. Thousands of people are already dying and being pushed into bankruptcy under our current health care system annually, so this is the kind of issue that will motivate a lot of voters. Part of the way to defeat Trumpism and McConnellism, is to go after some of the funding sources that put them into power in the first place. Actually, I don't see how you really beat them long-term without doing so.
7
@LT How do you convince people who rightly see the rich buying influence in government that Medicare for All is a good idea? You tell them the truth: that a huge benefit of a single-payer system is that it destroys the health insurance industry. Voila--no influence.
5
@LT Medicare for All is "not the hill to die on"? Whatever hill we're on at that moment, many of us are already literally dying under the current system.
The problem with trying to go to a highly regulated private insurance system is that private insurers grew way beyond what they are in other industrialized countries. They need to be cut out of the system so that their corruption of it will stop. That is what Medicare for All is about.
3
Mr. Krugman. The Dutch system is by no means perfect, but it does seem to be effective in ensuring we all have access to excellent health care while keeping the cost under control as best as we can.
There is a government orchestrated pressure on health care institutes to work as efficiently as possible, by handing control of the budgets over to private insurance companies. This pressure is created to drive the costs down and at the same time move budgets to quality care for all.
This approach has its problems. The health professionals complain about small budgets and low wages. And the insurance companies do have a lot of power if they control the budgets. We also suffer from pharmaceutical companies that take extreme profits. But in general I think we are constantly looking for the right balance and so far so good.
In our system we can choose individual plans but often also have the option to participate in plans provided via employers. So it still sounds like it is pretty similar in terms of flexibility to your Medicare for America proposal.
It is unbelievable that the GOP has prevented Americans access to affordable health care, just because it wasn't one of their own that created Obamacare. That is probably one of the most abhorrent offences ever undertaken by a political party in the USA.
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@Dutchie: The Netherlands is a very small country with a very different populace and a very different form of Government. I doubt seriously that a hybrid allowing private insurance to run the budgets would work in our country as well as yours, if for no other reason American businessmen are not like the Dutch, in a nutshell if there are ways to game the system to increase profits for their shareholders or bonuses for themselves Americans will figure it out, it is after all what our Chicago School business model is based on. Does The Netherlands have an average salary of twenty million for their insurance honchos or some walking away with astronomical sums like McGuire and his billion dollar going away package? As for Obama care it was designed to fail, largely written by insurance and drug companies with unrealistic assumptions like healthy people voluntarily contributing, this is not Holland.
10
@Dutchie "It is unbelievable that the GOP has prevented Americans access to affordable health care"
Actually, it's not. The ceaseless drumbeat of the GOP is tax cuts for the wealthy, middle finger for everyone else.
13
@Dutchie. However, so-called Obamacare or the Affordable Care Act WAS BASED on a plan implemented by Republican Governor Mitt Romney in Massachusetts...
12
I am progressive and strongly believe in universal healthcare. It is a disgrace and tragedy that in 2019 every American is still not covered. However, I do not understand the attraction to Medicare coverage. Here is what I do not understand:
1. If Medicare is such excellent coverage, then why do 16 million seniors also purchase private insurance plans in addition to the Medicare they are already receiving?
2. If Medicare is so much better insurance than private insurance, then why do so many physicians limit or do not take on Medicare patients as opposed to private insurance patients?
3. If Medicare is such great insurance then why do so many seniors still today, covered by Medicare, end up in medical bankruptcy?
4. If Medicare is so much better than private insurance employer based plans then how come Medicare does not cover vision and dental like private insurance does?
I understand why people hate the insurance companies and drug companies...its the national pastime. But, why would anyone want to give up their private insurance for Medicare coverage that provides far less coverage and less access to doctors and clinics?
Unless the "Medicare for All" crowd can get the 156 million American people covered under private insurance over that hump in a believable way, the Democrats, I am one of, should get use to losing elections.
2
"[W]hich system should Democrats advocate?...the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins."
1) You don't know how healthcare for all will "play" between now and the election - Sanders' 2016 campaign put it squarely on the map, forcing naysayers like you to triangulate on behalf of 'medicare for america' now; and it is quite possible that the movement and public opinion will continue to shift towards it as it gets better known. But the only way to determine that is to educate people more through demands for it, not by partial measures that ignore the pernicious leech of private health insurance.
2) As to what is 'most likely to pass in Congress' - your 'medicare for america' is more likely to pass if people are demanding healthcare for all, since, inevitably, initial proposals are whittled down: if anti-healthcare for all people feel threatened by that legislation, they'll actually be more willing to support medicare for america as a fallback option.
3
@Jackson
Like, last time right?
As mentioned in some of the comments here, we first need to replace DJT. That means getting elected and gaining a congress actively concerned with governing. Once either of those goals is accomplished we work on specifics to fix (all fixes are temporary) the cf that is the present administration.
That being said; given the present topic of health care I would like to see a monetary analysis of current expenditures on health care from all sources including employer/employee contributions and the cost of the various proposals being discussed.
3
Ideological purity in the last election gave us the current catastrophe. When the left does not get what they want (Bernie) they stay home and sulk. There will be no support for a system that threatens employer provided healthcare or one that poses an existential threat to the private insurers. The path to universal healthcare is to improve the ACA and make certain everyone, young and old, is in the pool. If the left demands purity the Democrats will go down in flames. The right will continue to believe the lies from the current occupant and vote against their own interests.
4
I am not concerned about whether we have a government-run payer or a collection of private payers in the mold of the Dutch or Swiss models. But the devil is in the details. If we move to the latter form, both the policies and the businesses will have to be at least as strictly regulated as the European examples. The policies will have to offer a comprehensive coverage of conditions and treatments, without exception. And the businesses will have to be non-profit, without shareholders reaping vast rewards for patient misery and insurance executives earning obscene salaries. But most importantly, whether government or private, healthcare costs will need to be set significantly lower, again on the European model. In a parallel op-ed today, Elizabeth Rosenthal points to discrepancies in American and German prices for insulin— $137 vs $50 — and this is just the tip of the iceberg.
Frankly, I’m not optimistic. On coverage, I expect that the American Taliban will again beat their breasts about contraceptives and abortions, and there will be a political kluge. And I fully expect that insurers and providers will throw gobs of money at legislators to make a private system with all sorts of loopholes that allow them to evade cost reduction and non-profit requirements. The GOP will obstruct, just as they did in the case of the ACA, and corporate Democrats will look out for their masters, just as Max Baucus and Joe Lieberman did a decade ago.
4
Americans are first and foremost customers, not citizens. Under the for-profit health insurance system established by the ACA, we're now chained to the for-profit health care Marketplace, waiting our turn to be gutted financially. It's like we're one big factory farm and we're the piggies.
As Marine Gen. Smedley Butler attested to personally ( 'War Is A Racket'), our government has a very long sordid history of assisting corporate profiteering exploiting military personnel (aka 'human resources') to do the dirty work to open and expand so-called free markets.
The ACA essentially drafted us all into the ranks of civilian human resources to expand the free market. It always comes home, doesn't it? The ACA made us all conscripts serving the healthy profits of the Marketplace. It's ironic that President Obama put us in those chains.
We must support Medicare For All as if our lives depend on it. Anything less is akin to New Hampshire's state motto: 'Live Free (of Health Profits) or Die"
People Over Profits - Medicare For All
4
First things first. I think Jay Inslee has it about right. Our generation is the first to experience the impacts of Climate Change, and the last to be able to do something about it.
If we don't combat Climate Change effectively, then little else will matter. However, in order to do so, we will first need to overcome the influence of big money in politics. I favor this double-barreled approach, and will vote for anyone who will put these two issues front-and-center.
2
Medicare for All is a non-starter. As someone who has been on Medicare for a few years I can state I would rather have my old employer plans where I didn't feel diminished or nervous about cost. It is unfortunate that employers started giving insurance as a benefit. That was when we didn't have such sophisticated options for treatment and medication. We live longer but at a cost. How much does medical insurance add to a car we make for export? Employers should not have to deal with an issue far from why they exist. I blended plan of public and private may work best. There are plans in Europe we could study. We all need secure healthcare plans and the public option should be the basis, not whether or not you are employed or employed by someone who actually offers affordable card. (The gig economy is growing,) My comment seems all over the place, but when I simplify it I mean forget Medicare for All and move in the direction Dr. Krugman suggests. (Sorry Bernie and Elizabeth)
3
...Except that fewer and fewer of us are satisfied with our employer-provided health benefits. They get skimpier every year, with growing copays, deductibles, and exposure to the nightmare of balance billing and out-of-network providers. If we're talking about political feasibility we should acknowledge that even the so-called lucky ones are as open as we've been in half a century to persuasion on the efficiency of single-payer health care.
1
Bernie Sanders' Medicare-for-All will never happen. We don’t need a debate. The evidence is already in, and it is overwhelming: the US health care system simply cannot turn around that quickly. There are too many obstacles: not only political, as so often cited, but administrative, legal and financial as well. It is a classic case of the perfect being the enemy of the good.
If you doubt this, I urge you to read Charles Gaba’s powerful blog post of 2016, still relevant today: http://acasignups.net/node/3085
I believe a consensus is developing that adding Medicare as a public option to the ACA marketplaces will in time accomplish what we all want: a true single-payer system. That approach is described in a plan, Medicare-for-America, which is well summarized here: http://tinyurl.com/y39vbv8k
For a more detailed discussion, I point you to Jacob Hacker, one of the plan’s authors: http://tinyurl.com/yd3ffxa9
For further thoughts, I recommend this comment by a reader, James Ward: http://tinyurl.com/y3hjmv5g
Paul Krugman is right: Medicare-for-America is the position the Democratic Party will ultimately have to adopt.
4
the problem with government only healthcare is it relies on Congress funding it. how quickly do you think they will get cheap?
2
Health insurance companies, which since 1945 have been given and have asserted control over health care providers in this country, are too entrenched in the system to be easily dismantled. The resistance (and cost) to such an effort would most likely doom any such legislation. What would work is a public option, government sponsored and available to anyone who wants to unburden themselves from an employer policy which keeps them umbilically attached to a specific job and employer. People can chose to keep their current policy or change to a subsidized public option which should become more affordable the more people choose it. If this is incremental, if this is Medicare for America, then that is the way to go.
3
Your Money or Your Life.
I am a health care industry and insurance company investor, and unlike doctors and health care workers who care for people, I do not. I care for profit and the CEOs of all of the companies in which I invest, work for me the stock holder.
Our goal is to make as much money as we can off human illness and suffering, while providing service in a manner that keeps us in business and within the law as our attorneys interpret it.
Profit drives our policies and practice, not what is best for patients and the nation.
The old time highway robbers used to say "Your money or your life" and many of them were caught and hung. But isn't it great........ we can take all of your money, and sometimes even your life, and yet remain respected pillars of the community.
Our nation has socialized military, socialized police, socialized legislatures and socialized court systems, because if those institutions were turned over to capitalists it would subject America to great harm and expense perpetrated by people like me. For profit health care is no different.
It is illogical to allow profit to be part of any system we must use to avoid suffering and death, because like the Mafia, business will use the inherent leverage to extort a price most cannot afford, but all must still pay.
12
"It’s a discussion in which ... nobody has any idea what he or she is talking about."
Facts. Policies. Plans. Debates on topics like health care, especially between candidates in the primaries, is a goat rodeo. Until and unless our political debates focus on, and are limited to, candidates' priorities and realistic solutions, those debates promulgate three silliness we saw amongst the GOP slate of 17 in 2016 - attempts to out-snark their opponents, especially Trump, and an unproductive shouting and insults free for all.
"So Democrats should try to make this a real debate, one about the best strategy for achieving a shared goal." Make a standard process that requires specificity, limits comments to their own approach, bans attacks on other candidates, and emphasizes focused presentation of intent and implementation.
Good luck.
1
I think it is unfair to paint advocacy for Medicare for All as some kind of ideological purity test. People are merely advocating the solution they prefer. For myself, I am not in favor of a system that preserves the insurance/medical complex which has driven up prices and dare I say "gouged" America for decades. I also do not favor "subsidies" for private firms, even to prop up affordable service provided by insurance companies. I can envision the army of lobbyist pushing congress for higher and higher subsidies to support their current business model which would again have the American public being "gouged".
3
Regardless of what surveys tell you, don't assume that all Americans with employer-provided health insurance are perfectly happy with it. Their plans might be very limited, with unaffordable deductibles and co-pays for anything more than a short office visit, and they might also have stringent caps on the amount of care their plans will pay for.
I will bet there are a lot of Americans dissatisfied with their employer-provided health insurance who would be willing to entertain single-payer, as long as they were given an honest explanation and not pie-in-the-sky dreams. Go find them, Democrats!
3
The health care debate surrounding the form of insurance that would be best for Americans can not be meaningful if the high cost of pharmaceuticals is not addressed. The government has shown reluctance to negotiate prices with the pharmaceutical industry at a time when treatments for common disorders such as rheumatoid arthritis can cost tens of thousands of dollars per year.
If health care insurance systems do not have reasonable ways to contain pharmaceutical costs , the argument that Health care for all can bankrupt the country will easily gain traction. It is important to let americans know that in most of the world pharmaceutical companies have their prices determined in such a way that the health care budgets are not depleted. This is a big part of the reason that health care is affordable in countries like Denmark, France and Germany.
The coming health care debate needs to address how health care access has come to be held hostage by pharmaceutic companies that have engaged in outrageous pricing with little to no concern for how such pricing channels back into making health care unaffordable for millions of people. If the costs of pharmaceuticals and how the government intends to bring them under control is not a part of the debate, one of the principle reasons for inequality of health care access will not have been broached, at a time when this subject needs to be front and center !
Wanting one of the largest deductions from one's paycheck to be consistent and effective from year to year is not a purity test. As someone in his 50s, I have living memory of insurance that works. However, every year more voters who remember affordable good health insurance die and are replaced by voters who are too young to remember a health care system that actually works come on board. Medicare for All is about demographic changes not political ones.
1
Hi Paul - Just a note that Beto O’Rourke actually has spoken in favor of the Medicare for America approach on the campaign trail (you indicated that no one had endorsed it as of yet).
1
Until we stop treating medical care as an aspirational privilege to be earned, nothing will change.
1
Prof. Krugman defines “Medicare for All,” as "replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly." The problem is that Medicare itself is not a "program in which the government pays most medical bills directly". Under Medicare the government pays no medical bills directly. All payments for Medicare Part A and B are made by private Medicare Administrative Contractors. For Medicare Part C (Medicare Advantage) claims are paid by the private insurer chosen by the insured as are all Medicare Part D prescription drug claims. No matter which type of coverage the individual there are copays and/or coinsurance that they either pay themselves or are paid by the state through Medicaid. Medicare is lousy insurance that could not be legally offered by private insurers under the Affordable Care Act. There are no limits on the out-of-pocket costs. For that reason almost everyone on Medicare has some other form of insurance, either employer sponsored coverage for active or retired employees, a private Medicare Supplement plan (Medigap insurance), or Medicaid.
Most of the financing for Medicare comes from the providers themselves. For example a patient needs oxygen at home. The provider bills $404.52 a month for the rental of a concentrator and related supplies. Medicare only allows a charge of $75.61 and their private agent pays $60.49 with the patient paying $15.12.
1
“A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
I believe this version would also require a provision in the law which requires employers to add the amount they pay per person in healthcare to individual salaries. Some employers might see getting rid of healthcare as a windfall for their bottom line. The additional salary would help pay the taxes required by the new health insurance.
1
It may be all moot after the insurance and pharmaceutical companies ramp up their advertising and spend millions, if not billions, to demonize anything except what we have now.
3
The other strategic concern regarding healthcare -besides exploring the most suitable fit in the US culturally- is the question of other key priorities: jobs and infrastructure; climate change; voting, citizen participation and election financing; deaths of despair, rural and urban; tax equity, etc. Many of these goals have broad support as well upon which to build common ground for other long term fixes.
Where are all these people who are satisfied with their employer-provided health care? Before retirement I was afraid to use my health insurance, which cost my employer and any employee unfortunate enough to have to use it a bundle, coming as it did with ever higher premiums, deductibles and co-pays, coupled with the impossibility of obtaining an accurate estimate of what anything would cost. Most people I know with employer-provided health care are in the same boat.
The key, of course, is that countries that provide universal health care based on private insurance regulate basic health insurance policies to ensure that premiums pay for health care rather than enriching the insurance companies' bottom lines. It is a form of not-for-profit insurance that I suspect would have made the ACA much more popular had that been included.
Whatever we do we need to stop letting the profit driven insurance industry dictate its terms.
3
The common factor in all successful system is that pricing is not left up to the desire of businesses to maximize profits in the "free market". The individual health care consumer does not have the power to keep prices and expenses down. Government must act essentially as bargaining agent. This is what must always be emphasized - only government control can reduce costs. If that is accepted the exact nature of the system does not matter so much - as Krugman says, that is just a fact. It could be left until Democrats actually get control - there would be renegotiation then anyway. A platform could include several alternatives.
3
The more I look at the issue, the more I think the next steps are to step away from the insurance industry and start looking at scams in the medical industry. Drug prices would be a good start. We do subsidize a whole lot of that expensive research. I get it- it costs money to develop drugs. But we have a system of grants and research institutions that do a lot of that research. A full audit of the companies that are selling drugs in the US should happen.
Second, we need to look at our care providers. What is going on there? I saw a bill go to my insurer for excess of $1000 for me to take a multiple choice test, have a drug screen and talk 5 minutes to a nurse to set up my next $1000 appointment for a "meds visit" with another nurse to get some xanax for some situational anxiety. In this case, my PCP would not (at a $750 appointment) prescribe me xanax which I asked for at my yearly exam ($1000 with bloodwork). She wanted me to get a more professional opinion. That's $3800 to get 10 pills of xanax for dental work and yearly air travel needs.
I changed PCP providers this year- my new doctor wrote me a new prescription at my yearly exam and told me if I needed more this year, I'd need to come back in and discuss if a different treatment was better.
There is wayyyyyy too much inconsistency in care and wayyyy to many financial hurdles to treatment, but a lot seems driven by your PCP on what those hurdles will be.
1
I miss a discussion of the Dutch system. Multiple insurance companies vie to provide the same basic insurance at the same price. Why? Because they each offer expanded coverage for more money. And this is where the capitalism kicks in. It’s socialized at the base and capitalized above that. Seems something Americans could swallow and it doesn’t destroy a lot of businesses-just makes them adjust so that there is universal health care.
2
Sorry Paul, but we got burned the last time. Obama ran on Medicare for All basically and then caved on the public option at the last minute to appease his donors. No, it is a purity test this time whether you and the rest of the establishment want to accept it or not. Lives are at stake. Peoples financial futures are at stakes given that medical bankruptcy is still happening even when people have insurance. We are fed up with the wishy washing "I believe ACCESS to healthcare is a right" disingenuous talking point.
You seem to think that those that have employer-based health insurance are happy with it. I have employer-based health insurance and every year my portion of the premium goes up and so does my deductible. In other words, every year I get shafted by the private insurance companies that raise our premiums. We are always changing insurance companies looking for the lowest rates. I think we are on our fourth insurance company in 10 years. So please, stop with the employer-based insurance as an excuse to mean people are not supportive of an Australian type Medicare for All plan.
I will be voting for the person who supports, unequivocally, a Medicare for All system. Period.
4
When I was very young I wanted the best baseball glove. When i got to my teens I wanted neat clothes. When I got to my 20's I wanted a fast, sleek car. When I got to my 30's I wanted a house, in my 40's my kids to get into great colleges. in my 50's I wanted a bigger, fancier house and my wife wanted a gourmet kitchen. In my 60's I wanted a big screen TV, an iMac, and a fast car. Now I am in my 70's and I want really good health insurance. What fun. I am glad that people in their 30's and 40's are coming around to understand what is really important, Health Care Insurance instead of a fast car.
1
The two types of “Medicare-for-xx” are not in conflict. If Medicare is extended to the public, at cost and age-adjusted premiums, employers will adopt Medicare coverage as their employee medical plan.
Dr. Krugman recognizes that democratic socialist countries use a variety of administrative options to deliver health care. None of the options are foreign to us. We already have in place the three major administrative options: Medicare, which is government-administered, Medicare Advantage, which is administered by private insurers, and VA health care, which is government administered and staffed with government employees and contractors.
The VA option, which is like Britain’s National Health Care, is impractical for America since our private practitioners are deeply entrenched. Private practitioners require a burdensome clerical system for processing and paying claims. Private practitioners are not methodically supervised and evaluated. So, we cannot hope to realize the efficiency and effectiveness of British health care.
We know how to deliver and administer low-cost, high quality health care for all Americans. We lack only the will.
3
Paul , right here in the Times today we have more descriptive insult upon our so-called world's greatest healthcare system. Elisabeth Rosenthal asks
Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55
Just more evidence Americans pay double, triple than others around the world pay for essential drugs. It is not just doctor, hospitals, testing costs but life giving drugs spiraling out of hand even with insurance.Pray for those without or inadequate insurance. So you go to a doctor and hope you can afford the medicine.
Is the present system that encourages insurance companies, pharmaceutical manufactures to rip us off the best America has to offer?
7
Great column, with one exception. You say that none of the announced candidates has endorsed Medicare for America. In fact, Beto O’Rourke has endorsed it and has made the arguments for it you make here.
1
While some who call themselves "conservatives" might prefer that sick and disabled citizens who can't fully pay their way just vanish to pay for the tax cut of the Republican Party financiers, that is not what will happen. Without good health insurance, ill and injured working Americans often become poor and unemployed Americans. They stop paying taxes, families lose breadwinners and society picks up the cost of both healthcare and welfare for them and their dependents. . There is no doubt that giving all Americans good healthcare, would extend their ability to work; make them more productive; Keep families together; Avoid bankruptcies, and actually do more to make America great than slogans on hats. The ACA, (Obamacare), should have been named the keep Americans Working Act, because that is exactly what it accomplishes in the long run.
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I do not write to advocate any particular government insurance scheme. I write to emphasize the Great Deception being practiced by most proponents of every scheme proposed. Krugman also practices that Great Deception in this article.
The Great Deception is that any of these schemes will provide healthcare. These are insurance schemes, not healthcare. There is only one way that more or better insurance can result in more healthcare. That could occur if there are more resources available that could be used to provide that additional health care. If more resources are not available, then insuring more people will only redistribute the same amount of health care that we currently have. That may or may not be desirable, but it is certainly not increasing the amount of healthcare which is what the nation really needs.
Are there more resources available to increase health care? Sadly, there is one critical resource whose supply cannot easily be materially increased. More hospitals and clinics could be built, more CAT and MRI machines could be manufactured. But where are you going to get more physicians?
Do you think there are currently unemployed physicians ready to return to work? If you want to increase the size of medical schools, then for years there will actually be fewer doctors since some now in practice will have to become teachers of the additional students. You could dumb down medical care by having non-doctors treat people. Sadly, that is what will come.
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I agree with Krugman that we should keep all options open. But the choice between true single payer and a hybrid system comes down to a choice between simplicity and complexity. (I hope everyone read Tim Wu's essay yesterday on the Democrats' complexity problem.)
Single payer is the simplest approach for the consumer, with no insurance plans to choose among, no bills to pay, no insurance claims to file and far fewer worries about access to care or affordability. You go to the doctor and the doctor sends the bill to the government. Easy.
All systems that retain private insurance, however, preserve and even increase complexity. (This is a major flaw in the ACA.) With private insurance, people will need to continue to choose between confusing insurance plans, follow byzantine insurance company rules when seeking care, and file claims and pay bills when care is received. Anyone who has had a major illness in the US or has had to help an elderly person navigate the US system understands exactly how large a disadvantage that is. And let's not forget that we'd be adding even more complexity as people will also need to enroll for government subsidies.
Both approaches—single payer and a private insurance system—can provide universal coverage. But one is simple and convenient for people. The other remains a nightmare of complexity. The choice Americans will have to make is whether protecting the health insurance industry is worth all the hassle of dealing with that industry.
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I would like to think that if we had a public option, like a Medicare buy in, that over time the benefits would encourage those who chose other options to change their minds. The challenge with the ACA was fear of change which is our challenge with all new things. Maybe the Missouri motto of "show me" would be the best option.
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"And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
While this may be true, I would wager that once those people actually try to use their employer sponsored health coverage for anything other than routine doctor office visits, their satisfaction level will drop. Drastically. For myself and a loved one, I have experienced a frustrating dearth of coverage for things like a needed test to help diagnose worrying cardiac symptoms to availability of psychiatric services. We both have employer sponsored health coverage.
When you take a closer look at our system of high premiums and deductibles for inadequate coverage, you really need to ask yourself a question: how could any other system be worse than this? As Dr. Krugman aptly points out, the Commonwealth Fund provides us the answer on an annual basis.
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It is human nature not to want to admit to a mistake, especially one that has been made, in light of sufficient evidence, for over 50 years.
Propaganda in the US is only secondarily political. Its primary purpose is to assure that we continue to make flawed decisions that provide income to those whose usefulness to society is a thing of the past.
Compare the scare tactics employed since the early 1960's on behalf of private vs. public funding of medicine. We have all heard the Reagan recording warning us of imminent Communism should we allow our older citizens to be insured by the government.
Just as climate change denial is amplified by funds provided by the fossil fuel industries, the "facts" we're told about the dire consequences of cutting private insurance adjusters, who one would imagine work on commission, out of the loop are as untrue today as Reagan's claims were half a century ago.
Americans claim to be savvy but fall victim to insurance company bugaboos just as they do to the claims of gun companies that freedom itself would perish should maniacs be denied automatic weapons. I picture us as the aging King in the Ring trilogy advised by the apparently sincere adviser who has only his best interest in mind.
Now we are embroiled in a debate between two systems, each of which would be immensely preferable to the Rube Goldberg system of coverage denial we have now. Routing healthcare money through a middleman seeking a profit is just wrong.
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Dr. Krugmman has neglected to mention the elephant in the room. That is, whichever strategy Democrats go with, a substantial portion of the body politic will wage a war of bad faith against it. It isn't that Republicans think Single Payer won't work. They are worried that it will.
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I especially appreciate this column, because my Democratic friends have taken to calling me a DINO and asking why I don't come out as a Republican for saying the same thing. We don't need litmus tests, we don't need to primary newly elected moderates, and we don't need the far left of the party to behave as a socialist version of the Freedom Caucus.
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I do not disagree with folks who are championing Medicare for all. But I would ask that this be amended a little to a Medicare option for all. Choice by those who like their health care plans should be given this choice lest we lose this segment of our population to Trump ranting.
The title of this piece is Don't make Health Care a Purity Test and by this Dr. Krugman seems to mean Don't reject a person if chosen in the primaries if they hold this view. If we do this in our coming election Trump will be president for four more years. Think about this. That a candidate doesn't conform tour views 100 percent should not be a litmus test. Democrats creating a circular firing squad because of relatively minor ideological differences is no way to win an election.
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@just Robert
Ever notice it is always the same people telling us not to aim for perfect and accept the less evil?
Ever notice everyone else is supposed to hold their noses and vote their way. Never the opposite.
Amazing how compromise is a one-way street.
And here we are 40yrs later. Following the same failed leaders, told to do the same thing. Toe the line. Don't make waves. Accept and expect mediocre incrementalism. 'Cause it is working out for them. Just not those nose holding.
Too bad. Look how much worse it could be.
Yeah, we have been looking.
40yrs. now.
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There has to be a public option. 1/2 of those folks that love that insurance paid for mostly by their employer is one layoff away from disaster if they get very sick, post layoff. It also ties them to an employer no matter how they feel about their work or the employer. Some working folks won't make a move because of the health insurance issue. What about an option for the ACA and lowering Medicare as it is to 55? The companies that provide employee health insurance would benefit to their bottom line as those 55 and older transition off the companies health insurance, older people could be free to retire earlier opening spots for younger people at the company who are. unfortunately now, much less expensive for the company.
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The private insurers would love a public option as it would take on a disproportionate number of the poor, old and sick—the population that offers the least opportunity for insurer profit.
Taxpayers (you and I) would then take on an even greater financial burden without a commensurate increase in revenue. Socializing losses and privatizing gains—the American way.
"156 million Americans currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
This is a trope that may be well worth questioning and correcting in public debate. Fairly healthy people - having maybe the usual hypertension, mild asthma and the one or other gallbladder or carpal tunnel surgery - may be quite satisfied, but what truly matters are the few people that experience actual serious illness. While the care in the US can be very good, the relevant questions are: are the bills getting paid? Is the self pay going to bankrupt me? How much time and effort do I have to invest into bureaucracy (payment and health insurance issues)?
You might want to measure your satisfaction with your local fire department based on its ability to quickly extinguish fires - and not be impressed because it has shiny fire engines or a nice community barbecue.
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I know a retired couple, not quite eligible for Medicare, who pay right around $1800/mo. for their health insurance. My Medicare premium is about $130/month, plus a supplemental plan to cover dental, hearing, pharmacy.
If I didn't have extra coverage that included 80% of the cost of hearing aids, it would be a strain to buy a good pair. A good pair of hearing aids at Costco runs from $1800 to $2500. If that same pair was purchased at one of the hearing aid centers other than Costco they cost closer to $5,000 and up. A lot of seniors who live on Social Security cannot afford that amount.
3
This is all part of the problem where no one wants to report news - they all want to be analysts. As a voter, all of this is just noise. I want to read about actual policies. We can all dream about pie in the sky dreams but at the end of the day, I want 3 thought out policies and the ways to finance them that are understandable by the general public.
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ANY national program that tells American citizens they have to give up what they have now and go to something unknown will fail...or, at the very least, cause the party proposing such changes to lose repeated elections. That is the resounding message from Obamacare. This stark fact bounces up against another...
...The single most important thing that could be done to improve "the general welfare" (as the Constitution says) is to find a way to make certain that all Americans, rich, poor and in between, have access to health care.
We are now in a time when it is generally recognized that health and prosperity, and its evil twin, poverty, are closely tied into good or bad health. Poor health helps to cause poverty and, in turn, poverty helps to cause poor health. The downward spiral then requires intervention with some form of public funds but, had better health care been available at the start, the spiral could have been stopped.
Obamacare was cobbled together as a compromise at the onset to try to avoid the fate that confronted Hillarycare: immediate and flat out opposition by the massive insurance industry.
There's another huge problem: American businesses view government programs as a fire hose of money. They are highly skilled at exploiting programs to enrich themselves at the expense of taxpayers, so cost controls have to be a vital aspect of anything going forward. In other words, it is all a complicated mess that could sink any politician whose hands get into it.
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The two individuals in the picture accompanying this op-ed, the opinion of Professor Krugman, are holding signs claiming that healthcare is a right. I disagree, healthcare is not a right; if it were it would be free. Even under a universal healthcare system, which most Americans believe would be free, because they have been told that by their liberal caretakers, healthcare would still cost a pretty penny. The American taxpayer, me and thousands of other hardworking Americans would be paying for it.
The recent WH Economic Report by the WH Council of Economic Advisors says that MFA would be "inefficient, costly, and likely reduce, as opposed to increasing the population's health." It states also that the tax increases needed to fund MFA would lead to a 9% decline in GDP by 2022.
Is such an economic calamity worth instituting a single payer system? No, I think not; but if it is, I believe that each and every America should be required to take personal responsibility for their health, like stop smoking tobacco and weed and lose weight. As it is I am against spending Medicare/Medicaid dollars on the healthcare of people who do not make an effort to take of themselves in the first place.
No, healthcare is not a right; in fact, its a privilege, a reward for those who lead healthy, spiritual, moral, and ethical lives; who respect their bodies and minds, not abusing them as most people do; and who thank the Lord, who created it in His image in the first place. Thank you.
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Southern Boy - I do not understand your statement that health care is not a right because it's not free. What!!?
Obviously many in the USA and other advanced countries disagree with you. In the countries with guaranteed health care coverage, people don't go bankrupt because of serious medical problems - an all too common problem here. And their infant mortality rates are much lower than ours, and their life expectancies are longer.
I'd pay higher taxes for guaranteed health care much more willingly than I pay taxes now - for an inflated military budget.
Not to mention things like a border wall, a fantasy of our deranged current LINO. Leader In Name Only.
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@Mel b.
Until the liberals take away our rights as documented in the Bill of Rights, ever heard of them, we do not pay for them; they are free for us to exercise.
We pay for healthcare; its a service, a commodity, a product. As the consumers of healthcare, we purchase it, as in the Obamacare healthcare marketplace.
Yes, many in the USA and other advanced countries may disagree with me. They want something for nothing. You write that "In the countries with guaranteed health care coverage, people don't go bankrupt because of serious medical problems," but the nations do, as described what would happen to the US in the WH report. Many nanny states are suffering from the weight of their costly social programs. Look at Germany. As for their longer life expectancies, that has more to do with personal responsibility than free healthcare.
No, healthcare is not a right, never has been, never will be. And it will never be free, someone has to pay for it. I will pay for mine thank you, but not yours. Cheers!
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@Southern Boy
Yes, that is exactly what god thought too....oh wait.
No that isn't even close to what god preached.
Republican Jesus maybe?!
(Headshake, facepalm )
No, better to stay the course. 45,000 people dying each year. 1 million declaring bankruptcy. 30 million not covered. 100 million not able to use 'cause of expense. They must all be god's rejects. The one's he doesn't love. Not worthy according to you. You ever been in a pediatric ward S. Boy?!
Too bad, so sad.
Right S. Boy?!
Hope you never have an accident.
'Cause god kills plenty more moral and ethical folk than either you or I.
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An excellent point, difficult problems require pragmatic solutions, not ideologism. Like a good marriage, universal health care requires compromise.
Anyone who advocates for Bernie Sanders' Medicare-for-All is advocating for the status quo, and is probably a "corrupt shill for the medical/industrial complex." I know this will offend, but I say it to make a point. The Sanders approach will never happen. The evidence is overwhelming: the US health care system simply cannot turn around that quickly. There are too many obstacles: not only political, as so often cited, but administrative, legal and financial as well. It is a classic case of the perfect being the enemy of the good.
If you doubt this, I urge you to read Charles Gaba’s powerful blog post of 2016, still relevant today: http://tinyurl.com/y3hjmv5g
For details as to how this public option might work, I recommend a comment here by James Ward: http://tinyurl.com/y3hjmv5g
In addition, the blogosphere is filed with commentary on this proposal. Try Jacob Hacker’s longer discussion at: http://tinyurl.com/yd3ffxa9
I believe a consensus is developing that adding Medicare as a public option to the ACA marketplaces will in time accomplish what we all want: a true single-payer system. Paul Krugman is right: that is the position Democrats will ultimately adopt.
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@Ron Cohen
Correction: Find Charles Gaba at: http://acasignups.net/node/3085
The key reason Medicare for All is better than Medicare for America is that you cut out the costly, unnecessary, complex, gate keeping, arbitrary insurance companies. You will never get the benefits of everybody in, everything covered as long as you keep all these other options.
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What there needs to be and most certainly what will not happen is an objective analysis of all the options, side by side so the voters can make an informed decision with an estimated look see as to what things would look like 10 years down the road. Voters hated the ACA until they saw that, despite some misstatements about it ("You can keep your provider". That wasn't 100% true. But neither is "if you change insurance plans at work, you also will have the same providers"). Included in the analysis should be the Republican "plan" or lack thereof. People also need to be aware that not "having" to subsidize insurance of the uninsured doesn't mean you are off the hook, financially. Paying for their very expensive care in the ER is subsidized care. ER care cost could be dramatically reduced or eliminated if people got preventative care through subsidized insurance. Add in the not very obvious extras like Medicare for all being able to negotiate drug prices or the great reduction of paperwork, much of which is indecipherable and the side by side comparison might just change a lot of people's minds. Instead we have catchy labels. SOCIALISM. PRICE GOUGING. FREE MARKET. Labels that advertisers use like TASTY, SWEET, or DELICIOUS. The press needs to help voters intelligently decide what is best for them. So we don't have people believing "MEXICO WILL BUILD THE WALL" only to find out Americans aren't just paying for the wall, they are paying for it twice.
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Universal coverage is not a question of capitalism vs socialism. It's a question of supply vs demand. The private health care system has not figured out how to supply medical care to meet the need for that medical care. Nor is satisfying the full demand for healthcare even on the agenda of that industry.
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Australia is not "Bernie downunder", it is a mixed government/private system. The wealthy are encouraged through tax incentives to purchase private insurance, but everyone is covered by the public system.
I'm a Teamster. My coverage resulting from negotiations between union and employer (UPS) is, arguably, the best blue collar coverage in the country (zero deductible, $10 co-pay...no kidding!) I do not want to lose it, I do not want to see it changed with the chance of it being compromised.
My coverage should be the bar that all workers' policies aim for, regardless of the system bringing it to us
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UPS has a young workforce compared to the average employer so it is cheaper.
I don’t believe that all employer insurance plans should be scrapped, but most people would be better off with Medicare.
Medicare for All is a poison pill for the Democratic Party. It will become the wedge issue which drives those on the margins of the party to the Republicans screaming "Socialism!" and "Venezuela!" at the top of their lungs.
I favor a "Medicare for Any" plan where you may buy into Medicare without being made to do so. Medicare for All is like making all shoes the average shoe size of the population. It might work well for some but others would find their shoes falling from their feet and the remainder would live in constant pain.
The status quo is criminally unworkable. I challenge any legislator, liberal or conservative, to spend half an hour (or more) trying to explain an insurance EOB (explanation of benefits) statement to an older and slightly confused recipient of same. I have done this in my prior medical practice--it felt like I was sitting in a taxicab at a drive-in movie watching the film and the meter both spool on.
By whatever name, any plan must be explicit, negotiated and fair and above all else as simple as possible. It's hard enough dealing with the ravages of illness without added unnecessary complexity.
Primum non nocere, indeed.
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Those who use most of the healthcare $$ are the elderly. The young for the most part are unlikely to have a super expensive to treat condition or illness. Do we really know how much Medicare for all would cos or is all of this in fact a guesstimate?
At this point in time I am not entirely sure as to what the greatest problem for people and esp. women healthwise will be given the strong anti-abortion, even anti birth control legislations.
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We are only 10 million people here, 1 million of us born somewhere else and in recent years most likely coming here as asylum seekers from all the wars you can possibly name.
I am certain that from a public-health standpoint, these 10 million get far better care at the lowest imaginable cost than any group of 10 million Americans you can point to, matched only by using SES criteria.
I have long experience with American medical care as seen both from a family vantage point and my individual vantage point. The care that would have cost me most has been given me in retirement, in the USA via Medicare + Aetna Private complementary insurance, in Sweden via Universal Health Care.
I vote for the Swedish model that continues to offer private as well as public care.
As for Krugman's valid point that so many Americans have health insurance connected to employment, I still pose two questions:
How much did samples of those people still have to pay for major kinds of health care? Give examples.
What happens when they lose their job. Give examples.
Can there be a rational debate in this my very own 21st (more like early 20th) century America?
Show me.
Only-NeverInSweden.blogspot.com
Citizen US SE
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Krugman is doing us an important service. We have to resist the recurring temptation for American exceptionalism and look at the ways this has been successfully done. Democrats need to emphasize the goal of universal coverage over any pat answer.
That’s what shows ability to govern. This is a solved problem, but we will fail to solve it here if we make it harder than it has to be.
For the record, T. R. Reid’s book gives a good overview of what’s out there.
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I'm very disappointed in this analysis. Americans may say they are satisfied with their current insurance at any one random point in time, but once they have to start using the system, everything crumbles. Our health system is a disaster. Giant deductibles, copays, in-network and out-of-network byzantine structures. Horrible customer service or no customer service from insurance companies, hospitals, doctors, and the drugstore chains. The entire system is designed to benefit itself and the wealthy shareholders of the companies involved. It is not at all designed for the patient or to promote health.
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@Paul
You will not get 'customer service' with a government run anything if that is what concerns you. When the government runs something you are only a number--nothing more. By the way--my private health ins. is great and my co-pays and deductibles are very reasonable.
@Driven. Actually I've had much better customer service with the government agencies in New York State.
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A good discussion.
Democrats need to keep their eye on the ball. We need some sort of universal health care system. We need one that can get through Congress and get signed by a president. We need one that the political opponents cannot turn into a cudgel that gets the reactionaries back in power and largely or completely reverses the gains made. (Remember what happened after ACA was enacted?)
EVERYTHING else is of lesser importance. How it's structured, who supports it, what other alternatives are imaginable, what model might be the most elegant or the most desirable - none of that matters nearly as much as getting a decent system enacted and successfully defended.
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I'm all for a form of single-payer healthcare, but one thing I keep warning others about is that declaring a thing and making it a reality are usually 2 ... very ... different ... things.
The obvious 800lbs gorilla in the room is the insurance industry itself. It employs 2 million people and contributes ~$2.5 Trillion to the national GDP. We need some way to deal with that or else we're going to have 2 million out of work and lop off a chunk from the GDP - not good results, especially if you want any reform to be supported popularly. The biggest problem I have with Mr. Sanders (and with Ms Ocasio-Cortes as well) is the avocation for change now with either an unspecified means or relying on technology which hasn't been discovered yet. (and please note: I have great respect for their individual intelligence; I just don't think they've really thought the problem through. The last thing we need is more Bumper Sticker Logic) Last year, Mr. Sanders released a plan which would have cost $3T per year - an amount which is roughly $80k per year per person in the U.S., making it actually more expensive than the existing system. Whatever we decide, we're not going to get rid of the current system overnight. It's going to have to be a step-wise change. I'd just like to see the candidates lay out what those steps would be, instead of just declaring (like a character in the sequel to "2001 a Space Odyssey") when asked what is going to happen reply "Something wonderful."
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If the goal is universal coverage, the allowing people to pick & choose between private & public plans will never work. That is not to say we could not have private coverage for those who want to pay for it IN ADDITION to the public plan. Even the UK has that, but for 3 important reasons, an efficient gov plan must treat everyone the same.
The 1st one is obvious. It is much, much cheaper to administer a program where everyone is treated the same than one that has Medicare, Medicaid, VA, Indian health, TriCare, etc, AND 1,500 different private insurance policies (not counting Part D Medicare).
The 2nd one is that if the public option is like the improved Medicare of Medicare for ALL, it has to treat everybody the same while private plans can develop plans that cater to the young, the healthy, and the wealthy. They can give bribes to companies to get them to buy their coverage, This would leave the old, the sick, and the poor to the pubic option or Medicare itself.
Krugman implicitly admits this when he says that the public option would have to have substantial subsidies for lower- and middle-income families. All this would raise the cost of the public option & negate any administrative savings.
The 3rd reason is that the universal gov run plan of other countries ALL have one entity that can gather data, analyze it, & make recommendations based on medicine, not profit. If a lot of people are covered by private companies which keep their data secret, we could not do this.
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As democrats we need to think rationally. If we allow the different elements to war against each other, as we did in 2016, the result will be the same. More Trump. We need to face the fact that turning the most “progressive” members into a left version of the Tea Party is of no benefit to anyone.
One last time. Russians did not elect Trump. Democrats who stayed home or voted for third party candidates elected Trump. There were far more than 77,000 democrats who stayed home or voted third party in Michigan, Wisconsin and Pennsylvania in 2016. That was all it took.
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It’s not a surprise that different approaches work well: successful health care reform accounts for a country’s ethos and culture. These are messy and complicated, which is why we should be wary of ideological purity tests, whether they demand MFA or full privatization.
Personally, I’m for what will allow all people to see a doctor when they are sick, and for that to happen sooner rather than later. I don’t much care whether insurers and providers profit (or not).
In addition to their national health care systems,other countries have put into place massive cost controls. Pharmaceutical prices are controlled,in some countries insurance profits or limited, there is no advertising of prescription drugs. These countries have been able to take the fat out of health care and thus reduce health care costs as a percentage of GNP. No system will work in this country if we do not take the same approach.
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I think it's hard-wired into our politics. Take an idea that makes sense, demagogue it, institute a purity test including it, and make it all-encompassing and mandatory.
The Republicans have the Freedom Caucus. We Democrats have some loud people who are gaining media attention at the expense of more rational actors. And in the Democrats' case, it is the media (again) that is doing the Republicans' work for them, just like it did in 2016 (oh my gosh the emails!). Making stars out of photogenic young people. Why not just have them go into acting? Oh yeah, politics and acting are on the same level, and there is a lot of cross-platform movement. That is how we got a backwater media star as our president.
2
There were, and still are, many ways of addressing the immigration issue, but “Build a Wall” was a simple, brilliant, slogan that got voters to the polls. “Universal Health Care” could do that, (and it would help to announce that Mexico is going to pay for it.) Of course the details are important, but the litmus test exists, whether you like it or not.
It pains me to see the Democratic Party take an issue that is a clear winner for them, and tear it into a bunch of losing pieces.
There are multiple ways to lose the election in 2020. Turning the need for better health care into a fight among Democrats is one of them. People bought the idea of “repeal and replace” without ever having the faintest notion of what “replace” would look like. Let’s not get bogged down in the details: Universal coverage, yes or no?
5
If done correctly, Medicare for America would result in a steady movement from private insurance to the Medicare option. This would also solve the problem in remote areas where the number of private insurance companies offering policies is small making a Medicare solution universal. Ultimately, I expect, that we will have Medicare and a few private insurance companies with expensive plans aimed at the very rich.
It would be difficult to directly implement Medicare for All. A policy that will force all of those insured by their employer or union to change their coverage and put all the medical insurance companies out of business. This would not be popular by many who have coverage through their workplace.
3
Medicare for all would give workers freedom from their employees. And it would give employers freedom from that worry. It would sideline insurance being in the healthcare business which would be marvelous for our health. It would reduce the cost of drugs tremendously. What's not to like? It is trillions cheaper then a blended system.
2
@Carolyn Egeli you do realize that insurance companies negotiate drug prices on their formulary. Whereas Medicare is forbidden by law to negotiate drug prices or limit the formulary. Thus Medicare for All is not going to magically reduce costs for drugs, indeed it could make them more expensive.
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@Joe Sabin
REAL Medicare for All will do away with that center-right policy brought to us by the Bush Administration in concert with Dennis Hastert and their Republican cohorts.
1
@Joe Sabin why not change that? Why can't they?
If the Democrats want to attempt to do anything, they have to win and to do that they have to stick together and vote for the candidate chosen and not sulk and complain or Trump wins again. It's very doubtful that they can do that. Then they can work on creating a fairer and cheaper healthcare system. There are certainly enough examples around the world to investigate and consider.
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@getGar
We're already hearing from 'Bernie Bros' that if their candidate doesn't get the nomination, they're going to stay home or vote 3rd party again (like they stayed home or voted for Jill Stein in 2016). We need to remind them that that's how Trump got into the White House in the first place, and if they want to get huffy again, all they'll achieve is him doing it again. We can't afford that.
1
Any attempt to create a system without a relatively important role of private insurance the rich could buy and use will fail. America is America.
1
As far as mechanism goes, we cannot dismantle the large insurers--already embedded in our health care system. We need their expertise. The government is not going to take care of all the services they provide (some will undoubtedly assert they do not provide much). We do need to revise the insurance system which is responsible for the excessive overhead of our health care. We need to stop paying too much and overselling health care services.
So on many levels Mr. Krugman is correct. We should not be arguing about labels; we should be finding a way to provide affordable universal care. Our current Medicare system is not socialized--the government does not control all the delivery and management systems. There is no particular reason to start now (whether or not we go to single funder).
1
@JSKI tend to feel the major medical insurers have created a smoke screen to hide resources that should be used for people. the billing system tier pharmaceuticals, multiple ceo , and administrators all of which dont ever see a patient. There are so many people ringing your home phone seeking to sell health care insurance is a indicator of the money thats in it, which isnt directed towards patient care nor nurses wages.
1
@JSK
A good start would be to put earning caps on CEO salaries and require all insurance companies to be non-profits.
Then we can co-opt upper management of those companies with agency oversight (essentially replace the existing private executives with public ones). Still not perfect, but it would at least keep all the existing insurance workforce in place and bring down costs.
However, like any solution, 2 things are required: 1) money has to be removed from the political system or else those with money (and have the most to lose by utilizing a public option) will just buy their way into stopping it, and 2) people have to trust government again, and the Republicans have spent 40 years selling the notion that government is a problem to be excised, not a power for solution based on the collective will of the electorate.
Good to see Prof. Krugman's realism about health care. He shuns the progressive wish to destroy private health insurance which a large number of Americans rely on with some degree of confidence.
2
Krugman mischaracterizes the Dutch system.
Briefly the Dutch system is a two part system.
Long-term treatments, especially those that involve semi-permanent hospitalization, and also disability costs such as wheelchairs, are covered by a state-controlled mandatory insurance. So this part is like Medicare for Al.
For all regular (short-term) medical treatment, there is a system of obligatory health insurance, with private health insurance companies. These insurance companies are obliged to provide a package with a defined set of insured treatments. This part is like the Swiss system. In fact what Krugman vaguely describes is the Swiss system, which is not two part.
The Swiss system does rely entirely on private insurance companies, but BOTH the Swiss system and the short term part of the Dutch system have the following parts:
The gov writes the basic policy which all people must have.
All companies must offer this policy unchanged.
THEY MAY MAKE NO PROFIT ON THIS POLICY.
Here are some per capita costs in 2016:
US - 9507.2
The Netherlands - 5385.4
Switzerland - 7919.0
UK - 4192.5
Australia - 4708.1
Canada - 4643.7 (also Medicare for ALL)
I have seen no public option type proposals which require all private companies to offer a gov written policy, let alone make no profit on it. It is clear that any such proposal would be a huge political fight. If we are going to have such a fight, why not go for a more efficient plan--Medicare for All.
3
@Len Charlap
Sounds like you have been involved in this discussion for many years--which you have ( https://www.nytimes.com/2014/12/16/health/the-odd-math-of-medical-tests-one-echocardiogram-two-prices-both-high.html ).
There are ways to do the things you discuss, if we can get past the politics and labels. That will be difficult.
1
I live in Canada and like our system - but it is not perfect (just much better than our neighbours to the south). Dr. Krugman makes a fair and valid point that there are blended systems in some countries that do very well (and are perhaps better than Canada's).
The other key point he makes is that there are millions of people who have health insurance that they are happy with and there is no reason to alienate them. Over time, perhaps, they will see that there are better options - but give them the opportunity to make that decision.
Ideological purity is counterproductive both because it is unnecessary to achieving universal excellent healthcare and because it is likely to fail.
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@Gary A.
I do not defend the US current system. It is obvious that it is woefully defective. But tell me, Gary, if Canada's system is so good, why is it that I see so many Canadians as fellow patients when I go to the Mayo Clinic for my medical care services?
Canadians have excellent medical insurance. But the quantity of Canadian medical care is another matter. Long waits for needed care is not acceptable, especially when surgeries are needed.
1
@Errol: This is a false dichotomy. We don't have to choose between the current U. S. system and the Canadian approach.
And the health care providers that we have here will still be here, whatever health insurance plan we come up with. There won't be any better place for them to be.
8
Introducing a stepwise program first for people aged 55 and older then five years down the road for people 45 and so forth
4
I don't think this is an election where we vote for what we want. It's an election where we vote -- en masse -- for what we don't want: Trump, and all his Republican enablers at every level of elective office.
If this turns into a national referendum on health insurance, plan on Trump for not just another four years but a level of political resistance and upheaval far more chaotic and disruptive than we've seen up to now.
Elections are personal and emotional -- not rational, considered, or cerebral. Healthcare will figure in -- as Krugman suggests -- but not as a deal-breaker so much as one of a number of progressive ideas that animate the Democratic nominee.
This election will be about Trump, no longer a fulminating threat but a proven toxic danger to America and the world.
He will run probing, provoking and playing to the worst fears he can excavate from rubble of his first four years, desperately creating as many new and even more frightening scenarios to panic his 50 million twitter feed followers that the "nobody" nominated by Democrats will be the American equal of Nicolas Maduro presiding over a failed Venezuela.
Save the policy and ideas for the next Democrat majority. Our job now is to reject Trump and his destruction of America.
Trump fights with a butcher's cleaver. We don't beat him with a scalpel.
315
@Yuri Asian Periodically, the US has elections that are about direction. Depending on how progressive the Democratic candidate and his/her policies are will depend on whether it is an directional election.
2
@Yuri Asian makes a valid point, that is a larger echo of Krugman’s views on healthcare. While the Democratic Party is energized, it is crucially important to keep centrist voters in mind as well as enthusiastic progressives.
It would be a tragic irony if Trump achieved a second term because of a centrist reaction to an over-ambitious left wing.
19
@Yuri Asian Agreed first priority is to remove Trump. This requires bringing in as many people from the right of the party as well as the left, by not scaring and not antagonizing anyone. This may be be uninspiring to many on the left, but the menace of another 4 years of Trump, to this country and the world is too extreme to leave any other choice.
12
This is a time when we need to step back, take a deep breath and think about the preposterous claims being made about medical insurance and Medicare for All.
Medicare does not provide 100% coverage. Medicare covers 80% and the patient covers 20% most often through private insurance. So Medicare is universal, but not truly a single payer system. Trying to penetrate the jargon surrounding the private insurance piece of Medicare is a daunting task. Co-pays and deductibles are a part of the system.
Medicare does not cover everything and its exclusions and limitations seem to be rather arbitrary. Coverage for eyeglasses is limited and for hearing aids nonexistent. Yet Medicare covers battery powered mobility scooters and I get dozens of calls every week touting medicare covered braces. Moving around in the environment is no more essential than seeing where you are going or hearing well enough to detect approaching vehicles or to communicate with your physicians.
Medicare is vulnerable to lobbying, political influence, and regulatory capture by insurers and providers. It is precluded from negotiating drug prices. Medicare is a payer and the amount it pays is influenced by Congress, the Patent Office, the FDA and other agencies. Medicare for All is likely to intensify the effects of lobbying, political influence and regulatory capture. Controlling the costs of health care requires thoughtful legislation and regulatory change.
5
Excluding private insurers is not simply an ideological "purity" issue. Our unique, administratively complex, fragmented, multi-payer system is the basis for our profound administrative waste and the source of inequities that reduce choice of health care professionals, impair access, and expose individuals to financial hardship.
The private insurance systems such as those in Switzerland and Holland have very little in common with our private plans. Since our private insurers are an entirely different animal, converting them to a European model would require replacement of our insurers with totally different social insurance models based on patient service rather than based on financial success in the marketplace. Since our insurers need to be replaced regardless, it would be more efficient, equitable, and affordable to replace them with an improved version of our Medicare.
Having spent a great deal of my professional life in management or consulting in the healthcare industry, I strongly prefer an incremental approach. The goal, ultimately, is that all residents have access to affordable healthcare. As I first step, I would suggest a public option within the Affordable Care Act, essentially the ability of any citizen to enroll in a Medicare plan. If private insurance companies could compete, so much the better. Second, I would convert Medicaid from a federal - state partnership to a strictly federal program. This would extend Medicaid under the Affordable Care Act to the 17 states that through pure spite and disdain for their citizens have refused the extend this benefit. Medicare and Medicaid could then be combined into a single program, with subsidies as necessary. Third, I would charge the government program with negotiating health care and pharmaceutical costs aggressively, bringing them in line with what most advanced countries actually pay. Fourth, I would extend Medicare coverage to include vision, dental and long term care. Again, it private or employment based plans could compete, so much the better. If not, we would evolve very quickly into a single payer system. The goal of affordable healthcare for all residents must the clearly stated. How we get there is a choice.
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@James Ward
I really like your ideas (mostly because I have taught health care policy and finance and they mirror my own thinking!). Most Americans (esp ones with employer provided plans) simply won't believe that politicians can sweep away a multi-trillion dollar system of private sector insurance in favor of ????? I am intrigued by the notion of getting rid of the toxic "state partnership" for Medicaid...where you live should not determine whether you get decent healthcare if you are poor....but it does....and my state has not accepted the Medicaid expansion so 850K Floridians are out in the cold. Expansion of Medicare to dental and vision might be ok, but LTC might be a bridge too far (look at the Rx drug coverage addition....it cost three times what was proposed).
47
@James Ward
I agree with most of your proposal. I would, however, recommend that hearing care be included in any approach to coverage. Hearing impairment is tremendously isolating and the cost of effective hearing aids puts them out of the reach of many Americans. Helen Keller wrote that the lack of hearing was more debilitating for her than the lack of vision.
63
It’s not fair people divest their assets and then expect private insurance (supported by premiums paid by all policy holders) or government programs to pay for their long term care. That really irks me.
8
Not to put to fine a point on it, but the ACA has undone my carefully-calculated early retirement-on-a-shoestring. My premiums tripled. My deductible would buy a nice used car. I receive nothing more than a flu shot until I am $15,000 out of pocket. I have no coverage beyond emergency charges when traveling out of the state of Maryland. God forbid I am admitted to a hospital in Florida. I have no choice of doctors. I don't go to the doctor when I should because I have spent the money on premiums. My provider builds centralized medical palaces that force me to drive distances (in a metropolitan area) for simple services rather than renting an inexpensive, local storefront.. The head of my "non-profit" provider makes millions each year. The list goes on.
Admitting that my information is anecdotal, in speaking to people who are on Medicaid, sometimes because they are not reporting cash income, they have the best coverage they have ever had. Me, I have to go back to work to fill the hole in my finances paying into this Rube Goldberg atrocity.
All of this because my income is a bit above the cut-off for subsidies. This is theft. In my working career, I paid more in taxes than many Medicaid recipients have made in gross income. How is this fair?
Thank God, owing to luck and moderate habits, I take no pills and am remarkably healthy for someone in his mid-60's.
Dr. Krugman has defended the ACA fiercely. I wish only that he would read the contracts of care that it has produced.
3
@D I Shaw
Question: If you're "someone in his mid-60's", why aren't you on Medicare?
Ask any senior citizen on Medicare, & you will find nearly universal love & approval of this health care system. Its overhead costs are a fraction of the overhead expenses of private insurance companies &, in our family's experience, you can choose any primary care physician or specialist you want.
4
@downeast60
I am counting the days until I am eligible for Medicare. Meanwhile, I need to deal with the $25,000 hole in my savings versus originally projected expenses in the five years since the ACA took effect.
I do not argue against a single payer system. Nor against a return to a private system that separates insurers from providers with adequate controls! But the ACA tried to provide healthcare AND redistribute wealth at the same time, and the outcome was grotesquely unfair to middle class people in the independent market.
In all its complexity, it never addressed the labyrinthine relationships between insurer and provider, nor required any transparency in pricing that would permit the kind of competition that keeps people honest. All it did was give some people a free ride at the expense of people scarcely better off.
One of Krugman's options was some variant of the ACA. In my view, it is a recipe for corruption and graft. My story is a cautionary tale!
Mr Krugman is on point today. I want all people to have health care Personally I have a plan employer sponsored that I do not wish to give up regardless of the governments promises. I dislike the Trump administration but will vote for him if I believe the Dems will force me from my plan
5
As someone who has been cycling through the ACA and employer sponsored health insurance I will say this: I'm tired of watching health insurance companies sacrifice my health and well being for their bottom line. No matter which side I'm getting insurance from there is always a problem. There are the monthly premiums, the yearly deductible, the narrow networks, the inexplicable denials, and the sheer aggravation of knowing that my health is the last thing on their mind. There is also the fear that even if I have insurance, should I contract a serious illness or have a serious accident, I will lose my job, my health insurance, and go bankrupt. Despite living in a country that boasts of having the finest care in the world I don't feel as though I have access to it. So what good does it do me or anyone else if they know they can't afford the care?
We need a health CARE system instead of the wealth care system we have. Doctors should not be forced to sign contracts that interfere with continuity of care. Patients should be receiving bills that they don't understand and may not have to pay. We should not have to hire someone to help us decipher or negotiate our bills. We should have a simple system that is transparent, available, and easy to access. This is the 21st century, not the 18th. People live longer and need medical care. A government that doesn't care about its citizens well being doesn't deserve to be in power.
904
@hen3ry
Hear, hear!
Medicare, here in still mostly red Orange County, CA, is a managed care only system. Now that I've moved to the southern part of the county, I have to drive 30 miles to see most specialists. There is no primary care physician in the town I now live in, so I will continue to see the same one I've been seeing these last 4 years, 32 miles away. In some disciplines, so many providers have dropped out, there is only one or two specialists for the entire county. Under Medicare for All, every doctor would "accept" insurance.
Voters' heads are being filled with all kinds of deceptive propaganda now to instill fear in them so they opt to "fix" Obamacare.
Not everything in life has to be for profit. The insurance companies are a superfluous middleman.
320
@Rima Regas
That's strange that you would have that problem. I'm a recently retired primary care doc from Anaheim and we certainly took both straight MC and the Medicare Advantage programs.
24
@Stella B
My current PCP is in Fullerton. I moved to the southern tip of the county. There's nothing local. Closest urgent care is in Irvine. Specialists are mostly in Santa Ana, Garden Grove.
18
There is no denying that too many citizens recieve inadequate health care. Every citizen is the market but no system has been devised to handle the market by using the capitalist rules of supply and demand. The system we now have is cruel because demand cannot be met with a supply system that is operated for profit. The demand side has no voice and no system for appeal whereas the supply side has absolute control and a voice that overrides consideration of the ethics and the morality of letting people suffer and possibly die unnecessarily because they have no access to and/or no means with which they can be healed. The system can be fixed but that means saying "No!" organized cruelty.
1
Could many of the “private” positions be coming from a “livelihood depends on not understanding it”? I’m assuming they’re quite happy with their cost and coverage? Would Medicare be a step down for them, or put them in a risk pool, which they’ve never had to help share the cost of? Is this why some Democrats prefer a private system? What has caused us to be last among other nations?
2
Considered purely from a pragmatic, political viewpoint, Krugman's support for a Medicare for America-type plan makes perfect sense.
That said, I often think about my late, 62-year-old colleague, who was diagnosed with pancreatic cancer (a malignancy, for those who don't know, widely considered one of the least curable).
He continued to work as long as he could, despite terrible discomfort, constant illness and even literally falling asleep at his keyboard. Why? Because he and his wife knew that as soon as he stopped working, he would *lose* his employer-provided insurance, and they feared what would happen.
That is, of course, precisely what happened. At a certain point, the boss said, "Sorry, you aren't productive enough here, we're going to have to let you go." Whereupon he lost his insurance and disappeared into the maelstrom of insurance options for private individuals (this was pre-ACA).
He died, as expected, and not because of his insurance problems. But his widow spent many, many years battling insurers and his former employer, eventually succumbing to bankruptcy and having to move in with an adult son.
Those who like their employer-provided insurance can keep it.... until they can't. Caveat emptor!
7
Krugman hits the nail on the head by pointing out that no matter how strong the argument is for a Universal Care single payer program asking the taxpayers to trust the government to do it right with a big hunk of their money at the outset will be a deal breaker.
6
@Donny Would you rather have a private insurance do it right with a big hunk of their money? A lot of that money goes to the CEO and stock holders at a tremendous cost.
1
@scott t O'm not defending the inefficient system that has evolved here after WW2 .O'm suggesting that in a nation that's lost near all respect for the institution of government you are not going to get enough voters to trust you with this kind of a gamble. There is no reason the ACA can't be built on.
I agree in general, but regarding employer-provided insurance, that is beginning to change as well. My employer provides Blue Cross--major, well-regarded insurance, right? We discovered this month that they have not been covering my 67 yr old husband's bills at the "normal" rate (after we met deductible) and when I asked, I was told that because he is of age to be covered by Medicare, they deduct what Medicare would pay from heir computations. My employer has never heard anything about this, it seems illegal to me, and given that benefits are a big part of salary negotiations it's a huge problem. And I have no idea why 2 years after my husband turned 65 this is suddenly happening.
The business model of private insurance is to deny claims to increase profit. It will come for your employer-provided blue chip insurance eventually too.
4
@LS
Upon retirement age Medicare becomes the primary insurance and your employer plan becomes the secondary insurance.
1
@R This is not explicitly laid out in my plan.
Stick with fact rather than let people drone on about "socialism." I have been back in the States on a work assignment after having lived in Europe for a number of years. Anecdotally, I can say that very few of my family, friends or colleagues in Italy, Germany, GB, etc. would opt for the U.S. health care system. But more analytically, just look at the data: Europeans enjoy systems that cost 1/2 of that here, and medical bankruptcy is virtually unknown. If you look at the outcomes, they are comparable if not better than those here. For those who want faster treatments/services, there are private doctors more than happy to empty your wallet.
And here's something interesting: Even my many conservative colleagues here in the states will admit that they would prefer the European system to ours once they are educated about how things work. Europeans pay for their system (it's not free), but those nations have not allowed insurance companies (better than the government?) and big pharma to inflate the cost of health care. Why, indeed do Americans insist on having their health care managed through their employer? Why do employers want the additional costs and irritation of managing the health care of their employees?
Americans need to better inform themselves rather than listen to all the noise they hear from the U.S. health care industry.
30
So Paul Krugman has come out (mildly) against Medicare for All.
Here’s his arguments:
1. Medicare for America will also get the job done
2. Medicare for America is more viable politically
3. The majority of Americans get healthcare through their employers and are generally satisfied with those plans
4. Medicare for All is a new untried plan and requires us to trust the politicians
None of these are strictly true.
1. Medicare for America is merely subsidizing private healthcare plans with perhaps a public option—people would still have premiums and co-pays and who knows how much? Medicare for America is fully covered with no surprises.
2. Medicare for America is more viable—perhaps—because it saves the for-profit health insurance industry which, coincidentally, are the biggest contributors to one of the sponsors and the second biggest contributors to the other. I other words, this proposal is being offered by politicians paid by the healthcare industry
3. Are they satisfied? Ask them if they’d prefer their existing plan or one with no premiums or copays that allows them to see whichever doctor they choose.
4. Medicare for All isn’t new and untried. Medicare is a popular successful program, more than 50 years old and would be modified and expanded to cover everyone.
Since people are dying right now from private plans that fail to provide sufficient coverage—look at what’s happening to 30 million diabetics—I’d say Medicare for America is too little, and way too late.
2
@Ray Katz
Bernie's Medicare plan cuts reimbursement for physician providers by 40% so your claim that patients would be able to see any doctor they choose is misleading. Many doctors wouldn't participate in that plan.
Most Americans will not be willing to give up the current plans they're satisfied and familiar with for something unknown that will raise their taxes. Period.
This is Bernie's doing. He helped to elect Trump by sowing division in 2016 and based on his hires this week, he's more than capable of doing it all over again!
1
The problem with the country depending on employers to provide health insurance is that it is not portable. So many industries have closed, moved overseas and its employees not only lose their jobs but their health insurance. While 156,000,000 receive employer provided healthcare, do they have a plan B should they find themselves suddenly and nonvoluntarily with out that job and that benefit? That is the question that should be put forward and discussed. For some time it has been the trend for business to be "smart", using AI, robotics, etc. continually shrinking its number of employees. Were I one of them, I wouldn't be so satisfied with my healthcare when I could lose it in the blink of an eye.
6
@Janet People who are self employed, unemployed or have an employer who does not offer health insurance can buy coverage on the ACA exchanges. My daughter does and she hasn't had any problems.
Dr. Krugman has summed up the issue facing the Democrats and the country perfectly. Let's have a debate about the ideas, the reality of implementation, the wants and desires of all Americans (not just the uninsured), and the political realities of passage. The ACA was a big step in the right direction in the respect that the coverage of pre-exisiting conditions is now considered mandatory.
Personally I do not favor Bernie's Medicare for All at this point for precisely the reasons laid out in this article. I have no evidence that our government could pull off implementation this system in such a way that makes coverage better for those who are already happy with what they have.
I would love to see a few states volunteer to be testing grounds for Medicare for All. I would like to see the right to buy into Medicare if you want. Then if the Medicare system proves itself to be worthy, people will want to move their insurance into that system because the coverage is good, the service is good, and the rates are good.
I am just glad we are finally having this discussion.
2
@Michael M.
The evidence that our government could pull it off is that at least twenty other countries have pulled it off. We don’t have to invent anything, just copy the people who have already done it.
The only people happy with the insurance they have are the people getting insurance through their employers. The rest of us are pretty angry. I pay $28,000 a year for my wife and I, and paid an additional $6,000 last year in co-pays and deductibles because I had minor surgery on my thumb. I need another procedure and I can’t afford it.
2
Employer-funded health care is a form of regressive taxation (for want of a better word). If I am a fairly low-wage worker, say I make $40,000/yr, my employer pays more than 25% of my salary for my health insurance. That money could be going to me. If I make $100,000, my health insurance constitutes a little more than 10% of my salary. Ergo, the low-wage worker is losing much more in potential salary than the higher-wage worker. People may be satisfied with employer-based health insurance, but they don't think about what it's costing them in salary. Even a flat tax, say 10%, paid toward government-funded health insurance would be more equitable. The 40k employee would pay $4k and the 100k employee would pay $10k.
9
@Kathe Geist
If you believe the money employers spend on healthcare premiums would automatically be reallocated directly to the insured employees, you're a very trusting person.
Kathie. No disrespect but if you think your employer will give you any healthcare savings, think again. This is America the land of the one percent
@Elizabeth
Of course, it's not guaranteed, but as long as employers are paying huge sums for insurance, it's guaranteed it won't go into salaries.
The health insurance and medical industrial complex will spend literally 10s to hundreds of billions of dollars to simply bury this effort under a torrent of lies and misrepresentations. The average voter will see nothing but propaganda about long waits for care, pulling the plug on granny, and government bureaucrats controlling treatment.
Absent a concerted effort by corporations, tired of the hassle and cost of dealing with medical insurance, to fix the problem, there will be no changes.
The health insurance and to some extent drug industries are rent seekers essentially stealing about 5% of US GDP, they are not going to let anyone pull the plug on them.
The average US voter can’t find Europe on a map, they definitely aren’t going to find their way through a thicket of industry lies to figure out what their real options are.
12
Slow down the bus. We haven't even figured it who all is running, much less come even close to thinking out the herd.
Until Democrats win some elections, it doesn't really matter what kind of healthcare plan we back.
If Republicans win, 99% won't be able to afford any healthcare, and if Trump wins, he'll probably do away with companies even being required to provide insurance.
And what's really bad is that we will all be needing it even more, because with climate change, things are going to get ugly. We are already seeing it.
3
This is not about “purity.” Basic negotiations include the concept of bargaining against yourself. The Republicans continue to lurch right - not unlike antebellum South Carolina. Given the overwhelming popularity of Medicare for all, its tactically premature to start paring it down years in advance of what will likely be an ever more opportune political environment in 2020. It’s a big mistake to brake progressive momentum - a historical weakness in the Democratic Party.
5
Paul Krugman is corrct America does not need a slogan to improve the availability of affordable heathcare; but instead a plan that works. Americans want choice. People do not want to lose what they have and they are satisfied with.
The solution is a Healthplan that allows everyone not eligible today for medicare to buy into Medicare or keep the insurance they already have. Those that cannot afford to buy health insurance there is Medicaid.
There you go, you have Healthcare for all.
2
@Martin We aren't satisfied with our HEALTH INSURANCE but with our medical care. Some people (including Paul Krugman incredibly) is confusing the two.
Insurance is an absolutely pointless step if we all have health care. This argument doesn't make sense. It's like being against investing in clean drinking water because some people get free bottled water from their employer.
3
That does not solve the problem of costs.
1
@Martin - "The solution is a Healthplan that allows everyone not eligible today for medicare to buy into Medicare or keep the insurance they already have. Those that cannot afford to buy health insurance there is Medicaid." The question is one of financing through taxes. Insurance rates are based on making the pool of money big enough to pay for the program. The more healthy people in a system the more needed money there is to pay for the sick. If getting into Medicare and Medicaid is strictly optional I would guess the tax rates needed to fund those who would use the system will either be too high to be affordable or force payment rates that doctors and hospitals will be unwilling to accept. No matter what kind of hybrid system we want, coverage will have to be mandatory (to make the pool large enough), and some part of the premium everyone pays will most likely have to help fund Medicare and Medicaid.
1
Thank you. The shallowness of recent discussion about health care is appalling and purity tests could cost Democrats 2020. The Affordable Care Act didnt become law just because some good people wanted it to really, really badly. It became law because proponents remembered 1990s Harry and Louise ads and had a winning strategy to deal with potentially fatal opposition from not only the insurance industry, but hospitals and the AMA. We have seen nothing resembling a strategy from Medicare-for-All purists. Great intentions and zeal alone do not a health care revolution make.
4
The cost, and level of treatment, of medical care in the US has reached a crisis level that does justify applying a moral test the problem. Hospitals are no longer charitable institutions but profit making entities. Patients are often shoved out of facilities too soon because the hospital makes more money if it can discharge patients prior to an anticipated diagnostic schedule. Staff no longer interacts in a manner designed to best care for patients. Millions are spent on advertising that could otherwise be spent to treat patients. Physicians' are being forced to join groups owned by insurance or drug companies. And care is not available to the least fortunate or those living in the poorest areas.
The system is clearly broken, and getting worse. While it would be unwise to label one cure as superior from a moral perspective, it is immoral to reject all attempts to remedy the mess.
6
Nobody is suggesting there aren’t theoretically varied approaches to universal healthcare beyond Single Payer MedicareForAll.
What we supporters of MedicareForAll as the vehicle to achieve our goal are suggesting is MedicareForAll is the movement with the momentum , the familiarity and the legislation in place to manifest the critical priority of ensuring healthcare for all.
In my experience those expressing doubt and offering alternative approaches are bad faith actors concern trolling to muddy the waters and protect the financial interests of the all powerful Healthcare Lobby.
Sorry Dr Krugman , MedicareForAll is my purity test and it’s well past time you get over your animosity to Bernie Sanders and use your privileged perch to effect moral and fiscal progress on literally a life and death issue burdening scores of millions of beleaguered Americans at the mercy of for profit corporate entities.
We have a healthcare crisis in this country . We have Medicare . We know it works, we know expanding it to all saves Trillions and thousands of lives and maybe , just maybe , adopting MedicareForAll as a public good can be the start of a healing process for a broken country where belief in our institutions and hope for the future is all but dead .
5
@Paul G Knox. There are far too many purity tests fragmenting our politics. Otto von Bismarck said, “Politics is the art of the possible, the attainable — the art of the next best”. The ACA would have had a public option, but it failed for lack of one vote. In order to pass most of the original bill, our politicians compromised to get what they could. They did not allow the perfect to drive out the good.
I’m pretty sure that we would eventually have MCA if we tried the more flexible plan first. Let Medicare sell itself. Those who love and don’t want to lose their employer-based insurance, will eventually come around when they hear about how well Medicare works from family, friends and neighbors. It will also be the death knell of the health insurance industry as employers figure out that MCA is cheaper for them, too.
Calling M4A purists the naive ones is an interesting gambit.
It seems much more naive to think that the American healthcare industry could actually be regulated after the top CEOs in the industry have gotten used to taking home on AVERAGE $20 million dollar salaries in the years since the implementation of the ACA (while leaving 30 million uninsured).
How did this get to be the more the pragmatic approach again?
4
Move to single payer.
But "grandfather in" employer based. plans.
No more would be established
Existing ones would last as long as their clients and their employers chose to use them,
3
"— almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
The issue is the other half who has to pay health insurance individually or have no health care insurance at all. To have a winning 2020 proposal, both sides should be addressed. Let satisfied employees keep their coverage and give the rest of America access to affordable healthcare. The key is affordable.
Take into account that Americans paying an annual premium of $16,440 with an out of pocket/deductible of $14,000, are not happy. It is immoral. This looks like Venezuela.
3
@Aurace Rengifo
Actually, a $16,440 premium w/ a million dollar deductible is more like Venezuela.
Nevertheless, call it what you want. If this country does not help out Americans with their healthcare rights the United States will sink even lower, people will die, healthcare facilities will shut their doors and close.
I’m a nurse of many years. I worked as a Case Manager on the insurance side and hospital side. I walked the trenches in hospitals during the 2008+ years of recession, no jobs, no insurance. I heard plenty of firsthand healthcare atrocity stories due to no insurance down at Occupy Wall Street. I have heard the horror stories of not being able to afford Obamacare, and have witnessed the ramifications of not having healthcare insurance. Employers have mandated higher premiums, out of pockets, deductibles. Some states, like Wisconsin under Governor Scott Walker, and run by a Republican legislature have even filed lawsuits to basically get out of helping the poor by decimating the ACA. They say they care about pre-existing conditions, but their behavior is opposite. In the meanwhile the costs keep rising.
Healthcare providers want to “do no harm” but our Republican government leaders today seem to never have heard the phrase.
18
Universal coverage is a winning slogan. “Build a Wall” was a winning slogan. “Build a barrier of some kind - metal slats, or concrete, or maybe a moat” would not have been a winner. “Several different ways of achieving universal health care” is not a winner. Universal coverage is indeed a litmus test. The details of exactly how it is achieved are interesting to you and me, but not to everybody.
2
@Peter
I get what you and a number of other commenters are saying - a simple slogan gets the public's attention better than complicated plans. But what it comes down to is which Dem will be the nominee and that person's plan is the one the Dems will adopt. It will be the job of the focus group people to come up with the slogan.
We can chew gum and walk at the same time.
So, let's advocate for particular plans, as long as this advocacy is based on the actual details of the plan -- not necessarily micromanaging it, but at least talking about goals, process to get there, how medical services would be distributed and/or limited, how doctors would be educated, paid, and available, how employers who now pay for medical insurance would be required to contribute (through higher wages or by direct taxation), etc. This would help clarify the issue
But as Krugman argues here, the most important thing is to get one of those universal health plans implemented. So don't turn advocacy into stubbornness.
All plans will have some strengths and weaknesses, and will require subtle flexible implementation. Be willing to join a bandwagon once one seems to be forming.
Begin by voting Democrats into office, and get your friends to vote.
5
@JustThinkin
Sorry, but as Dr. Krugman said, the most important thing is to get enough Democrats elected to improve health care, because otherwise the Republicans will surely make it worse.
1
@Bob Allen
You say, "get enough Democrats elected to improve health care."
I don't understand what you think your disagreement with my comment might be. My last sentence was "Begin by voting Democrats into office, and get your friends to vote."
I hear so often that people are satisfied with their health insurance coverage provided by employer. There are two themes the single player system would take care of it bother so many people with employer based insurance.
1. With single-payer, every doctor is “in network “ and no one would have to give up their doctor because their plan doesn’t cover him or her. If it is single payer, every doctor is in network. Giving up the doctor you want is such a common occurrence currently. Often the only way to keep your doctor is to stay with a health insurance plan that you don’t really like.
2. One single drug formulary. So many patients take the prescription from the doctor and try to get it filled. At that point neither the patient nor the doctor knows if their insurance will cover the prescribed medication. If we have a single payer the formulary would be the same for everyone. When you left the doctors office, you would know if the prescribed medicine was a drug covered on the formulary.
So a single-payer system would maximize choice, not reduce it (as those who defend the current system frequently claim). Patients can choose whichever doctor they want because with single-payer all doctors are covered. And it would either eliminate or greatly reduce the chaos that surrounds medication coverage.
7
This is gibberish.
All “single-payer,” means is that a single entity—generally speaking, some part of government—collects all the premiums and providers all the providers.
It doesn’t tell you anything about networks, any more than Medicare does now. And no, you cannot just choose any doc you want, for the very simple reason that docs only have so many hands, and there are only so many hours in the day. By the way...big GP shortage already, especially in rural areas, and worse to come due to retirements.
Somewhat similarly, the whole idea of a formulary is to tell you which drugs are covered and at what co-pay level. I serve on a JPA board; I assure you that nobody’s hiding this info like an Easter egg.
@Brian Budenholzer
You assume that doctors/nurses/techs etc. will work under single payer for the amount that you are willing to pay. Some will, many won't. Better start studying to treat yourself.
The key difference between the US and say the Netherlands and others hat have a private system is that hat in other countries private insurance is mainly nonprofit and much more regulated than the US. We could certainly move to a system like this but the profit motive needs to be significantly scaled back or removed. Easier said than done however.
2
You might actually want to look up what the profit margins are for insurers.
1
What I currently have is Medicare and a supplemental AARP plan. Without the supplemental plan I would be a beggar on the street after having been bankrupted by costs for radiation treatment. Sure Medicare is great but a single payer plan would be much better. I advise everyone to look at the physicians for a national health program site. This is a large group of physicians who have advocated for a single payer plan for many years.
www.pnhp.org
11
Republicans should support the single payor system for healthcare. The system would relieve businesses of a huge financial burden. Businesses could use that savings to raise wages. Many of the people who support the current administration are at risk of personal bankruptcy should a catastrophic health care event happen. In the rest of the world, the prospect of going personally bankrupt from medical bills is unheard of.
The Medicare for All plan would also give the government real leverage to control costs. And we'd take all the middlemen who all get a cut of healthcare dollars-out of the game.
A capitalist healthcare system by definition does not work. The current model asks: how many things can I find wrong with you and how much can I charge to fix them. Medicare for all would turn this paradigm on its head and focus on keeping people well.
4
Actually, Obamacare started pushing towards performance-based pay years ago.
2
@Skidaway
"In the rest of the world, the prospect of going personally bankrupt from medical bills is unheard of."
I don't know about the rest of the world, but in Switzerland, the most conservative country in Europe, the former president, when asked about the prospect of someone in his country going bankrupt due to medical bills, he said it would be a "national scandal".
Dems need to stop talking about “Medicare for All”, which the GOP uses as a political talking point for “Socialism”—the catch-all Republican word these days for all things bad. Instead, the Democrats need to brand the issue for what it is: “Health Care for Everyone” The goal is not to simply grow a government program; it is to provide quality health care for all. It is a common decency issue, not a Medicare issue. The question is how we do it, not whether we use an existing government program as a platform.
The GOP has been really good at setting the terms of the debate and defining issues as things they are not. The Democrats need to take back important issues like health care by framing them in a way that truly resonates.
24
What I think Paul misses in this piece is the moral outrage many have against the concept of private insurance, i.e. profiting off of the vulnerable sick AND creating a multiple-tiered system in which access to care rests upon whether or not you can afford it. Both of these pieces are inherent to any public/private system - no way around it. While I don’t think it should be a strict “litmus test” for primary candidates, I think Paul is underestimating the popularity of the moral case against any hybrid insurance model.
9
Moral cases are dangerous. They are full of self righteousness which is divisive. There is absolutely no moral case against hybrids which already exist and simplistic solutions spread misunderstanding and anger before any substantive thought and investigation.
I'm from Germany and we have the same system only with more people. So if someone argues against the Netherlands you can hold up Germany fyi. I worry for the US on healthcare because it is the most unamerican thing ever. When I think about the US I allways think of the melting pot where you take in the best things from other cultures and make it your own, why can't the US do that with healthcare?
27
Basically, that is what Obamacare did.
I am tired of the excuses. I am tired of accepting and voting for compromise democratic candidates--and by extension, compromising my values like clean air and water; REAL medicare for all; REAL consumer protections; recognizing labor as having fundamental value to the larger economy and treating it as such; sensible gun safety measures; respect for women who serve in the military; enforceable protection against age discrimination, etc. etc. I am tired of the threats by media pundits and fearful democratic voters that if I vote for someone that ACTUALLY represents my values, I risk yet another republican getting elected. I/we have compromised and compromised and compromised and look where it has gotten us...
8
I agee there shouldn't be litmus tests. The question should be which system will provide the most people with the best opportunity to receive health care they can afford. One can argue that private insurance companies should be continued for political reasons, but it's virtually impossible to argue that by doing so the cost of healthcare won't continue to increase. Multiple payers are expensive to administer and insurance companies need to make a profit. The Kaisser Family Foundation and VOX have both published excellent tools for comparing a variety of healthcare proposals.
Despite polls that indicate people with employer issued health insurance are satisfied, it's a good bet they'll be persuaded to switch to a government run system like Medicare once they realize it's cheaper, no networks and doesn't go away if they're laid off.
2
Paul, I'm not disagreeing with you that we need the debate, but with your statement that most people with employer provided insurance are happy with it. I'm covered under our state plan as a teacher, yet I don't go to the doctor like i should because of high deductibles and co-pays. That is not acceptable. Having insurance doesn't really help if using it is prohibitively expensive.
9
I'm hoping we get the Bernie plan, single payer. Most people would actually have greater choice of providers, & taxes aren't terrible if you're getting something essential for them. Health care is something we should feel secure about.
6
You lost me after citing a study that claimed the UK is tops in healthcare system performance. I think you'd find plenty of Brits who would vehemently dispute this ranking, and, having lived there and experienced their health system in comparison to the U.S.'s, I would agree. From excessively long wait times to make appointments, even for urgent cases, to wholly outdated facilitates, the U.K. is not a model to hold up as a success story we should emulate.
3
Their system works better than ours, and is cheaper, is the thing.
1
@Robert
Cheaper, but far from better! I wouldn't trust anywhere but the U.S. for any serious health matter. It's why the mega rich from around the world seek healthcare in the U.S. Let's be careful not to jinx it!
1
@R1NA, How many Brits go bankrupt due to their health care costs? Answer: 0. It's the same in Europe, where those citizens manage to have systems that cost 1/2 that of the U.S. and achieve equal or better outcomes.
The U.S. system to which you refer is ridiculously expensive and is not available to everyone.
1
Medicare has a 20% deductible for most services. This gap is often covered by supplemental private insurance.
Medicare reimbursed providers at MUCH lower rates than commercial insurance.
Do Democratic activists support exposing Americans to Medicare’s high deductibles?
Do they support a shocking reduction in revenues that will shutter many hospitals and other providers?
3
No, it doesn’t. Part A is covered by your lifetime cintributions; Part B has an 80/20 cost-share, until you hit your OOP max; Part D is separate, unless you are in a HMO.
The last thing Democrats need is a series of litmus tests of ideological purity on any topic. The goal is simple: beat Trump in 2020. Only after that can there be real debates about how best to reduce health care cost and expand insurance coverage. Any of the Democratic nominees should avoid any talk of "take and replace" employer health insurance. Offer "choice" instead to both employers and employees by making Medicare available to more people, starting at age 60 in year one, and working our way down bit by bit. Many people stay in jobs they hate just for the benefits. Employers are burdened by providing health insurance as a cost of doing business. Use Medicare to give both a choice.
4
I wish that Krugman and others of like mind would also explain that we cannot reduce costs unless the government forces the issue. And so... a medicare for all will be the only way to push costs down. The ACA accepted the conservative notion that larger deductibles and what are essentially side funds would give patients an incentive to shop for better costs but this was a flawed idea dreamed up in a think tank. The deductibles are killing the middle class.
7
I've never been able to figure out why an annualized insurance policy model, one that resets arbitrarily after 12 months, serves any purpose. Can someone enlighten me?
4
@Eben If you are funding with private funds, and the amount you spend varies (as it does with claim costs) then you must set a baseline for assessing costs. The policy year works well for that.
1
Very important point. Health care is for a lifetime If the US wants to innovate, let’s develop a system that does that, not copy imperfect systems that are paid for by our defense umbrella and apply to less diverse and spread out populations. The only way to appeal a medical decision by the government is at the ballot box if you’re still alive.
@Terry McKenna That might have some validity if health providing organization actually did some conventional cost-accounting . But they are generally using a cost-plus model, and spend their analytics on software that simply tries to price items so as to optimize for payouts by insurance companies. The startling reality is that many, if not most, hospitals have no good idea what it actually costs to do what they do. They are, however, good a constructing Chargemasters that are designed for the insurers, rather than the patients.
In some countries, for example, Denmark, everyone is expected to support the healthcare system from their first job to their last. The amount contributed is progressively scaled, but the obligation of society to the individual citizen accrues over a lifetime. That's why, Danish citizens who leave the country (and no longer pay taxes) for long periods, actually have to buy their way back into the system if they ultimately return.
Our so-called system has all kinds of classic externalities, agency problems, and arbitrage opportunities. The so-called value-add of insurers is really hard to pick up, especially when the decision makers are not particularly medically sophisticated (I know this from direct experience with Blue Shield that were initially denied by administrators who knew almost nothing clinically).
As someone who recently spent 5 years living and working in Australia I’m fairly familiar with their system even though as a work permit holder I was under private insurance. While my Aussie friends at times might complain about their system no one ever advocates switching to an American system. They are appalled that such large numbers of Americans are simply out of the system.
All that being said most Aussie opted to add additional private insurance to up their coverage (private room versus shared) so it’s not like they have no private insurance companies. But every Aussie has a basic level of coverage which is better than most Americans private plans. All of this paid for as a percentage of your taxes. So no opting out of the system.
Like Paul states how we get from where we are to where we want to eventually get is the extremely difficult part of the equation. Democrats have to be careful of walking into a Republican trap and think long and hard about how to do this.
7
Yes we need to be very careful. Prior attempts at health care systems have given us today’s GOP
Let's get health insurance out of the hands of employers and private insurers. Face it, a form of #medicare4all is already here for persons over 65 which the 156 million current employer insured will fall under. Some of the big problems with the current system that #m4all solves is people don't go bankrupt and the insurance is portable so people will have greater job mobility. So stop shilling private insurance, we need the #medicare4all plan that works best for the people.
10
@Thomas Goodfellow. You have to dig deeper. The insurers are better administrative models than the Federal government. Think of Medicare Advantage. It is very efficient. "Bigger" government is not "free." Single payer ( think of the Feds as a "re-insurer") is achievable without "socialized medicine." We can regulate insurers as we do with utility companies. Please read the "purple plan" from economist Lawrence Kotlikoff.
3
Netherlands has a fine system but pls note other features that makes it work: near-Free med school education, doctors on salary (nice amount but substantially less than most US specialists), strong regulations of prices and quality, and reliance on regulations rather than “malpractice” lawsuits to guard agains shoddy providers. That’s how they keep costs manageable. We would need all those to avoid health care costs going through the roof.
14
There are various premises that no one seems to want to confront and refine: economics says that patients should be sorted by utility. That is young people with a curable disease and a steady job have more, call it, marginal utility, if they should be cured, than an older person without a job and an incurable disease. Costs are involved, but they point to the puzzle: if one $10 antibiotic pill cures the first and a 1000 $100 pills prolongs the life of the latter, then ... You see the point.
As it is the system is scewed to favor those who vote and contribute the most and have the least marginal utility: retired, older people with acute and chronic (generally the latter) conditions. Of course humanity must come into the equations. But they are equations that can be balanced around a value system: a system of premises.
The premises should be stated upfront. Without them no one really does know what they are talking about.
@theonanda This becomes institutionalized cruelty as soon as you have an institution that determines "marginal utility" or if "utility" is defined strictly by monetary value. In fact and feelings, the 'marginal utility' of my 83 year old grandmother with fragile health and 3 chronic diseases is huge to my 4 children and her 4 great grandchildren.
5
@paradocs2
Being adults is hard. Society should be made of adults that are compositions of facts and emotions, willing to make hard decisions.
Also, the children mentioned require no medications. It is a non-zero sum game. You can keep your grand mother going and it will not be at the expense of the children.
Adult: The grandmother is terminal and a child is curable for what it costs to keep the grandmother alive another month, funds don't exist for both. Funds exist for one.
Also: don't bother with grandmothers and children, engage scientists if making viagra. It is highly profitable and biologically silly. The institution you mention is really bigPharma. They make the decisions. Money is the motive; the marginal utility is marginal profit.
Thanks for feedback.
You cannot keep costs down in a system where everybody gets everything, and endlessly maintains the elderly no matter what.
So I don't really get it I guess. Am I missing something? What's wrong with having Medicare as an underlying structure and then everything else-employee insurance, personal insurance, etc on top?
9
Less than we have now and better than what’s been proposed.
Once again, this columnist I love is, like many pundits, displaying a middle schooler's understanding of US politics. I know what the Constitution says. I also know it made no provision for lobbying, campaign donations and the resulting corruption. Not to mention social media and the opportunity to effectively use fear to guide policy.
We are the last major country to declare our health as a basic human right. We have a massive, disorganized health care system which is driven by profit. All insurance
And health care systems have overhead or administrative costs. But in our country, the opportunity for business entities to take in billions is seen as sacrosanct and held above health and welfare in importance. Especially by millions of voters at high risk of losing everything they have to health costs. And yet it is a major obstacle we continually fail to acknowledge and let enter the debate.
My point is that fear has been used in a corrupted political system to support profits over health care delivery. The landscape is just wrong for reform. We don't enjoy the textbook democracy Mr. Krugman naively believes. Clarity does not exist and public will is manipulated. Emotion trumps analysis. This keeps us stuck in the status quo, which means the system that makes billions treating our lives as no more than a calculation of profit and greed, remains the status quo.
By our failure to appreciate that our democratic process is broken, we are stuck in place.
5
Speaking of middle schooler understanding, you seem to think that Montgomery Burns runs the health care system. Things are quite bad enough without the hyperbole.
I agree that the Medicare for America plan in which those who wish to do so can keep their employment-based insurance is the way to go. First, will be the easiest to sell to the public and the plan least open to Republican scare tactics although I'm sure they will find plenty of opportunities to scare the public about ANY universal coverage.
I think the major consideration must be that if Democrats don't win in 2020 there isn't going to be any universal health coverage of any kind; there will be no infrastructure plan and no program to combat global warming. More regulations put in place to protect workers and prevent bank failures will be scuttled. We will probably see another tax cut for the wealthy. So, the message is: Democrats MUST propose programs which will appeal to voters. And, finally, we must find the right person to deliver that message.
5
A plan that allows people to keep their employer based insurance must also eliminate the tax break given to those employers for paying its portion of the insurance. Eliminating this break might cause a lot of companies to all of a sudden reconsider their generousness, driving more people into the Medicare camp. And it will expose people to the full amount they are actually paying for their employer based plan.
5
Oh yes, the same "government" that can't build a subway in NY on time and on budget, that can't fill potholes, that can't protect against flooding, that builds fighter aircraft only when they cost three times the original budget, that has been enmeshed in tribal warfare in Afghanistan for decades...this government is going to provide you with better healthcare along with a free lunch. Hard sell.
3
as always- most thoughtful guy on the opinion page. Great laying out of the issue and how we as a country might deal with health care for all.
2
Actually the first time I even heard of Medicare for America was when Beto O'Rourke said in an interview that he would support it, not Medicare for All. He even asked the reporter if he knew what it was - he didn't - so he explained it - exactly as Krugman did here.
Sanders has been talking about Medicare for All for years and years. But guess what - they tried it in Vermont and because of the cost (among many other obstacles) Vermont cancelled its attempt.
Democratic contenders for 2020 MUST stop saying they support Medicare for All - and say what Beto O'Rouke says. "If you like your private insurance, keep it. If you don't, you can join Medicare for all ages."
5
Health is basic to lead a good life. I am not necessarily against a universal system of coverage that requires a fair amount of subsidies so long as there is a conscious effort to encourage people to understand that health is largely dependent on good habits. Diet, exercise and mental balance. In turn these are under our control in that we are the only ones who can create healthy habits.
I admit that it would be incredible difficult and challenging for the government to monitor and rank our lifestyle choices. The idea would not be to prevent you from exercising your freedom to choose, but to make sure that there is an alignment of interests and a sense of responsibility. Should a person be entitled to receive heavily subsidized care for health complications later in life that have arisen as a result of decades of unhealthy and sometimes reckless choices. I would say no.
A good system that provides help to those in need, but also underscores the need of personal responsibility requires a tremendous effort in terms of education and effective gentle persuasion. We may not get there tomorrow or next decade, but benefits need to be to some extent contingent on the degree of conscious personal responsibility we display in our lives.
As a physician in Canada I hope I can add a couple of useful things to this discussion. There are some subtleties missing in Paul’s analysis of a single-payer (Bernie-style) system. Single-payer certainly does not rule out having private insurance to enhance coverage that is not included in basic government care. Often these enhanced insurance policies are paid for by employers. The government funded system we have in Canada for example provides for about 70% of the healthcare spending in the country, while the other 30% of costs (co-pay for drugs, dental care, physio, other peripheral health services) are split about 50-50 between private health insurance and out-of-pocket.
https://en.m.wikipedia.org/wiki/Healthcare_in_Canada
I agree with other comments that point out that conversion to a single payer system, however beneficial, would meet massive resistance by insurance companies (and other healthcare companies that are taking advantage of the current system e.g. pharma). The amount of lobbyist money poured in to stop it would swamp the electoral process making this type of change impossible.
For this reason the first step in any meaningful change in the healthcare system needs to be campaign finance reform. Once the big money is out of the way, a true healthcare revolution could take place, likely resulting in a much more cost-effective system that includes quality healthcare for all, and the availability of enhanced plans for those that want it. Good Luck!
14
@Tim Mullen. Whether or not that is a good proposal, given the Supreme Court's rulings on campaign finance, waiting on its reform probably means a very long wait. Let's not make the best the enemy of the good, assuming single-payer is the best system; Germany and Switzerland, in addition to the Netherlands, also have private health-insurance companies and excellent systems.
5
Insurance is not an acceptable vehicle for providing healthcare to anyone. It has to earn a profit. It has to protect its profits by limiting pay-outs and by drawing restrictions on coverage. It exists courtesy of the taxpayer-financed judicial system, which resolves legal conflicts that shouldn't even exist.
Insurance has become a critical part of our social infrastructure -- but one that is free from all constitutional and legal norms. It costs society a fortune, and delivers an inferior product. The US's free market has turned insurance into a government-protected venture that operates like the feeble factories of the old Soviet Union.
3
"...almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
Satisfied with the coverage, yes, but maybe not so satisfied that their medical care is tied to their job. What if a career move and one's medical care weren't bonded together? How many potential entrepreneurs are held back because individual coverage is ten times more expensive than employer group coverage? If there are children involved it's yet more expensive.
8
An additional note, when it comes to gaming out the politics of this issue rather than assessing the substance of the policy, Krugman should sit this one out. When the ACA was being debated, he strongly urged passage of the law, even sans public option, on the assumption that people would learn to love the law. Had a public option been in the law, odds are in October 2016, every insurance market would have had at least one insurer, and two weeks before the election, there wouldn't have been announcements about massive premium spikes for millions of people. In a close election, these issues matter. Even as someone who backed Clinton, I also understand pretty viscerally, what it is like to see premiums increase over 200% in recent years. The politics of enacting the Sanders plan will be very difficult. However, the Medicare for America is not a serious answer as a matter of policy or politics, and there's an argument, given the entrenchment of the privatization and market place scheme, that it would actually take us even further backward.
Articles like this miss the primary problem with the American system vs. any other system. Our healthcare is for profit. Everyone else's healthcare is not for profit. The Netherlands system absolutely will not work here because we are driven by the almighty dollar. They are not. It's not about private vs. public. It's about profit vs. non-profit. And I don't see our legislators doing anything to fix it any time soon.
4
Here’s the problem with Medicare for America: it preserves too much leeway for health insurance to weasel their way into the system and prevent it from both covering all Americans and lowering cost. If you allow private health insurance to remain as a critical component of healthcare they will do everything in their power to make sure the fundamentals of our system remain in place. We’ll be left with another u popular and expensive half-measure like the ACA.
Medicare for all is much simpler to sell and has a much higher chance of actually delivering on its promises (although designing the system would be more difficult, which is the trade-off). A system based on health insurance may have worked in America at one point, but they are simply far too powerful now to be allowed a day in the process. They will absolutely derail it.
Of course, PK doesn’t actually care about any of his. He is really just on his multi-year attempt to shiv Bernie Sanders and this is a convenient way to do it.
2
"...most of these people are fairly satisfied with their coverage."
It should be said that most people are satisfied up to the point that they hit the 'gotcha.' And there is a gotcha waiting for many people, who are then left with being denied necessary treatment, not being able to afford medication. ducking collections calls , or bankruptcy.
12
Paul, you're a brilliant man. Please investigate this: while universal health coverage, however we might achieve it, is an admirable and fair goal, the Insurance Industry in bed with Big Pharma will simply pour millions into lobbying efforts, sway the spineless creatures on both sides of the aisle, and thereby thwart any meaningful legislation. It's about MONEY, period, and we'll never see substantive change in our lifetimes.
2
As a retired person with excellent health insurance, I propose for everyone the system that I am lucky enough to have: Medicare, which pays most of the cost of my medical care and, more importantly, sets maximum costs for services, plus a private "medigap" plan that pays most of the rest and, also important to me, covers me when I'm outside the United States.
I understand Krugman's opinion. I would hate to have nothing but Medicare -- it pays 80% of the cost of service, but if I need to be in the hospital, even 20% would bankrupt me.
Changing everyone's private insurance to a Medigap plan, at 20% of current private insurance cost, would make voters happy and also move the US in the right direction.
8
When cosing between the various options, shouldn't there be another consieration: what is the option that's hardest for future republicans to destroy (by incrementally changing it, by depriving it of a budget) ?
13
There's a fundamental difference between insurance sold via marketplaces, and a system of public insurance provided collectively out of taxation. The "Medicare for America" model is basically another version of Paul Ryan's dream where all Americans -- including seniors -- are eventually pushed into an individual insurance market. The version of "Medicare" sold in the "Medicare for America" program is also the private, for-profit "Medicare Advantage" program. So you get the worst of all worlds -- Medicare in name only at a much higher cost to taxpayers. Sanders' and Jaypal's "Expanded and Improved Medicare for All Act" is a much heavier lift politically, but if enacted it would do more to actually guaranty actual, sustainable universal coverage, cradle to grave coverage.
4
The German system, which I have lived with for almost 20 years, with excellent care, is not a single payer system. There are public and private insurances, both regulated. The system works well.
I hope Americans will go for universal coverage above all.
5
Purity tests may have a bad name, but there is a serious question about the role of government in guaranteeing health care as a right which should not be avoided. Right wing partisans have long peddled mistrust of government involvement in vital human services as a tactic of persuasion, but we should be far more wary of creeping capitalism than creeping socialism. Here in Britain, for example, the NHS is constantly threatened by Tory politicians who promise to make the health service leaner and more efficient by privatizing various components of a necessarily complex system. It's clear that the Tories are gradually dismantling the service with the ultimate goal of total privatization, which will leave many citizens without adequate healthcare. The cunning trick of capitalism is to get people to believe it's the only game in town.
6
No system is perfect, but the key to success is the understanding that in economic terms basic healthcare is inelastic in demand, not so different than utilities. Whatever the system, public or private, it has to be heavily regulated and serve all the people. Even though the insurance companies have fought tooth and nail to prevent it, Americans are finally beginning to understand this.
In Israel we spend less than half of what Americans do, and everyone is served. It is a mixed system: There are competing non-profit HMOs which by law must allow anyone to join and provide them a prescribed basket of services, drugs plus hospitalization. The HMOs compete for customers. Employees check off an HMO and 5% is deducted from salary (similar to Social Security). Then each HMO offers supplemental insurance, which most families can afford for additional drugs and services outside the basket, and there is also private insurance and service for those who want more and can afford it.
There are chronic problems, such as under funding of public hospitals and some senior doctors who are difficult to access as they spend too much of their time with private patients. On the other hand, the tiered system also frees up bottlenecks. On the whole it works very well.
6
"It’s a discussion in which essentially nobody has any idea what he or she is talking about."
That is a refreshing confrontation with the truth.
Yes, it is true that all candidates with "profess" ideas. But which of them, if any, would actually do it in office?
Some profess it but don't even believe it. They've got public positions, private positions, and positions for every group they speak to.
Others might really believe it, but they would be ineffectual. They don't get things done. All talk.
It is about more than professing the right variant of a plan. I'd take any of a lot of different plans, from someone who believes it and would actually do it. But which candidate is that?
4
The country is not ready for drastic changes; such proposals are likely to scare voters. Republicans will label them as socialist, with an underlying message that Democrats would curtail our freedom!
Universal healthcare, tax-hike on the rich with payroll tax-cut on the first $20K & lifting of the cap but cut again beyond say, $200K, & higher federal minimum wage, eventually to reach $15 in 3 years, i.e., by 2024, ought to be Democrats' basic stance.
(This is my humble opinion; what would happen eventually is unknown. If the Democrats become too ambitious and scare the public, Donald Trump may get reelected)
1. Universal healthcare can be achieved by adding a public option & making buying health insurance mandatory, like having insurance to drive a car. Gradually, Medicare/Medicaid for All would happen.
2. A 70% top rate may not fly. At the most adopt Bernie Sanders's 2016 tax plan with a top rate of 54.2%, on over $10M. It's extremely important to specify rates on "over what amount;" in 1980 70% was on over $215K (about $650K now) Another example: Top state income tax rate in MO is only 5.9%, but on over $9.25K, while in CA top rate is 13.3% on over $1M. But most Californians pay state income taxes at a lower rate than most Missourians do, as the 6% starts at $61.5K; under that the rate is only 4% or less.
Actually Sen. Sanders's tax plan was moderate & detailed. It could be tweaked. His plan did not differentiate capital gain & wage incomes beyond $37.6K, for tax-rates.
2
"There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability."
I was stunned the other day to hear a supposedly serious journalist/anchor on one of the cable shows ask her panel what they could make of the most recent Iowa polling.
Her first panelist answered "It is way too early to even begin to conjecture". The second was more direct, "I'm not even going to answer that question, it's ridiculous to try and read anything into such early polling."
The anchor responded to these rebukes by laughing "I know. But I just LOVE polls", and turning to her third panelist commanded "So Betsy, do you think this poll shows Beto is likely the nominee?"
Lawrence O'Donnell stated on air that at a recent appearance by Elizabeth Warren, literally not one of the members of the media asked her a single question about policy. All they cared about was to ask her about Trump Tweets, and "What do you think is your path to the election?"
Apparently, for all of their mea culpas about their coverage of the 2106 election, the press has learned nothing.
8
I think "not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability." means the "discussion", such as it is, is fifth order. It's revolting.
6
I would be more convinced by Medicare for America if it had a mandate for employers, the solution that was offered in the 70s by that unreconstructed socialist, Richard Nixon.
9
The most immediate need is to give those without affordable group health insurance the opportunity to buy it. Many people are already covered by employer-sponsored group insurance - some by employers in the private sector and others who have government jobs at some level. The people out in the cold are those who don't belong to a "group" as defined for insurance purposes, either because they are self-employed or because their employers do not provide coverage. The Affordable Care Act has been trying to fill this gap, but politics has decreed that the fixes it needs are not to be addressed. A situation in which a family can go bankrupt from one hospitalization and be forced onto Medicaid - where the taxpayer has to pay the full cost of medical treatment - is as irrational as it is unconscionable. Take care of those without group health insurance NOW and stop wasting time grandstanding.
8
"There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability."
Reminds me of the derivative quality of Cold War intelligence as depicted in that delightful comedy "Romanoff and Juliet" : "They know that we know that they know ..... "
2
Exactly right. Focus on the end (universal coverage), and be flexible on the means.
I like the combination of lowering the Medicare age to 55 and expanding the ACA subsidies for starters, as several million people on the exchanges are getting hit hard because they don't get subsidies. Expanding Medicaid in the Red States that would rather kill their people than cover them is another couple of million.
I think in the long run the costs will force us to adopt a Medicare for All model so the government has the power to force down prices about 40% to European levels. This will be highly disruptive for those employed in health insurance, but we'll pick up lots of jobs in healthcare delivery and in other sectors that get a boom because people have money to spend on other stuff.
12
The problem with Medicare is that id doesn’t cover pretty much most of what decent group insurance covers such as teeth cleaning and maintenance , eyes vision testing and glasses and ears need hearing aids as you get older. Also very few therapists take Medicare especially in rural areas. Supplements are offered according to state policies and can be very high.
"There are many honorable exceptions, but an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability."
This is because "pundits" do not need to study the issues in order to speculate on who is more electable.
Having said that, this year my top criterion in the Democratic primary will be who is electable, in other words who can beat Donnie Rump.
5
Let's not snatch defeat from the jaws of victory here. The only thing that really matters in 2020 is defeating Trump. Along with the Republican Party, he is an existential threat to democracy. As much as we need the debate on health care, it pales in comparison to living in a dictatorship.
8
@PB I agree but I don't have a crystal ball to see which candidate with which policies can beat Trump, do you? Polls and pundits didn't predict Trump's victory. What makes any Democratic voter think they can pick the winner against him?
1
@abigail49
Having lived in several dictatorships (like Kazakhstan and China) I can tell you that it is all about divide and conquer. Trump and the Republicans will try to divide the Democrats. Keep the focus on kitchen table issues, and let the House investigative committees do their work.
The last thing that we need is for the Dem's to run around like chickens with their heads cut off.
7
@PB, Part of the reason that we even have a President Donald Trump is because the last Dem to run against him made him and his behavior the issue and didn't sufficiently emphasize ways that she intended to improve the conditions of the people who live in this country. Our bloated, inefficient, health care system is an existential threat to millions of Americans and a moral monstrosity as well. In order to win, it helps to build a coalition around a positive vision that actually will improve people's lives. A genuine, universal health care system is one way to do that.
1
About 75% of Americans have adequate health insurance. So, we need to address the issue of how to take care of the remaining 25%. This is a simpler problem than try to swallow something we cannot swallow. The focus should be on the expansion of affordable healthcare act. The other issue is control of healthcare cost including prescription drugs. Heavy taxes as in other countries to provide Medicare for all, may sound justified, but it also takes away the freedom on how one can spend their money. I prefer to live in US irrespective of healthcare system Europe and other nations have. Don’t convert America into Europe. If the Democratic nominee advocates Medicare for all, I will vote for Trump, despite the fact I contributed to Bernie in 2016.
4
First of all, the government is more or less broke, in that over half of all Americans are receiving either free or mostly free healthcare in this country, but the ability to pay all the bills for the programs of Medicaid, which has 75 million on it, all pay no premium, and it is set to run out of enough money to pay all the bills, Medicare, Part A Hospital has no premium for those 60 million who are on it, and set to run out of enough money to pay all the bills in 12 years, Veterans, current military, and former military, current federal employees, and former employees, Native Americans, and Federal Prisons. We have 330 million people in this country, and we should have a single Payer system, not government, but the private sector, mandated on a sliding fee schedule where all would pay, most a lot, because a very unhealthy population is driving health care costs through the roof, at $4 trillion spent last year. Most state budgets are driven by two items, public education costs, and healthcare. Our country is $22 trillion in debt, will spend over $1 trillion more this year than the revenue we should be collecting, if we didn't have legalized extortion through the over 70,000 pages of the IRS Tax Code that has given more tax credits for each child to keep those who make under $60,000 sedated so they don't complain, and realize that the President's family who are invested in real estate don't pay taxes, nor does Amazon, nor too many others. Congress that passes tax cuts? No!
3
@MaryKayKlassen—That is a canard that you need to raise taxes to have MFA. The key is starting an MFA program in a liberal state like Massachusetts. It is counterintuitive but MFA would work better at the state level than at the federal level because doing it at the federal level allows for deficit spending AND it would end up being a huge windfall for the well off with good jobs. You see in America we have a group of people called Republicans that will cut any tax Democrats implement to pay for important programs. ;)
So you go state by state for MFA and only people over 65 and on the ACA and Medicaid get the benefit of federal deficit spending. The people currently with good benefits through their employers continue to pay for health care and as they do today...only the health care spending goes from the employer to the state Medicaid office and that office runs the MFA program.
3
I had an idea which I thought Republicans might love it so much they'd hate it:
Permit small companies to purchase insurance for their workers on the Exchanges. Use this to get companies with the fewer than X workers, who are currently exempt from providing insurance, to buy insurance for workers. Then give them a Refundable Tax Credit for doing so. Good for business, good for workers.
I am a volunteer tax preparer. EVERY year, I see people who are supposed to buy insurance on the exchanges. They have the income to do so. They would get subsidies to do so. They simply lack the financial and mental sophistication to do so. Most of these people are barely literate as it is. Even the ones who are not indoctrinated by the Right Wing press--many are not--they don't have the ability to navigate the Exchanges or even find a Navigator. Fully 25% of our population is functionally illiterate, 10% is completely illiterate, almost 45% is innumerate.
I see at least a dozen people a year, who don't have health care and should-- they can afford it--and that's just me. If employers and insurance companies are going to be a part of the solution, we MUST find a way to take the onus for having insurance OFF the individual. We have far too many individuals who are simply not equal to the task of evaluating and purchasing insurance.
Buying health insurance is rocket science.
55
@Dejah - Very good point! At 85 I'm fairly computer savvy, and worked my adult life in hospital administration, so I have a fairly good ability to navigate the Exchanges.
When my retirement insurance benefit changed and I had to find just my supplemental insurance through an Exchange system, I found it quite difficult and frustrating. I can only imagine how impossible it would be for many seniors to navigate. And I personally know quite a few very intelligent retired seniors who are NOT technology savvy!
4
@Dejah
Rock solid reporting.
4
@Dejah
Thank You.
1
Dr. K,
I would like to suggest a new name for Medicare for All, etc.
Universal Health Insurance with the key requirement that ALL income earning Americans must participate in the program by contributing to the insurance trust fund at a fixed percentage of ALL income, no caps, and no special qualification for types of income. Income is income is income. The percentage of income that must be contributed would be determined as the real cost of using this system unfolds.
Could Americans also buy additional insurance, say from an American company or a foreign company if they can afford it but no income-earning American, not one can avoid paying into the Universal Health Insurance Trust Fund, UHI Trust
The UHI would be administered by the same folks who administer Medicare. At my last check, they were the most efficient, lowest cost administrator of health insurance, anywhere.
I anticipate that this new agency will use its universal database of the healthcare payments made to the clinics, private medical providers, hospitals for the thousands of treatments and diagnostic treatments prescribed will help the agency to develop standards for good health and well being.
This is our real objective delivering excellent care and promoting a healthy society, whatever their personal financial condition.
I am now 82 but still employed, but I now realize because of watching the developing requirements of my friends who require "assisted care". This can be expensive but so what.
6
The Congressional Democrats won Congress in 2010 and commenced legislating and passing the Affordable Care Act that the Republicans condemned, likely out of jealously as they convinced their base to deny themselves health care.
The Democrats have lost many elections from Congress and the White House to state legislatures after overwhelming psychological messaging by a wide array of Republicans since passage of the A.C.A. After it faded from minds, Democrats won last November.
Do you really think Democrats pushing for even more health care reform is going to win elections? The Democrats don't learn how effective the Republican machine is nor how to combat it. Instead of fighting to teach all Americans that health care is what they need, the Democrats let the machine continue without public debate. Dignity never won a fight.
The Republican base has proven to be unreceptive to the idea of caring for their own health and Democrats should abandon the idea of universal health care as the Republican base doesn't want it. Instead, to get us beyond the abuses of the private insurance industry and still provide cost effective health care, make it optional under Medicare buy-in so those who care about themselves will be cared for. The question is then, how do we do it without bankrupting Medicare with sick people? Effective education in lieu of mandates will teach everyone they need health care.
I have yet to hear this pointed out. Democrats are too timid.
5
@PATRICK
It Democrats loose in 2020 because of this, they can start a not-for-profit Medicare for All Democrats, with corresponding party subscription fees. That may win in 2024, if there still is an election then.
2
@PATRICK. You must have missed that virtually every single democrat ran on fixing healthcare.
In all these years, Democrats have said; here, now you have health care insurance, but failed to teach the public effectively that they needed it.
Medicare pays 80%. This leaves plenty of room for private insurance for the other 20%. The way to do it is to expand medicaid, covering individuals (a mandate) and giving employers a choice. Any system should offer preventive care, a yearly physical and a doctor visit with no deductible. As part of the premium that amount would belong to the payer, refunded if not used.
1
"156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage."
We may be satisfied with the coverage itself but we’re not satisfied being beholden to an employer to get it or that they control what plan we receive and can (and do) switch plans when it’s least convenient.
6
@Alix Hoquet: Krugman's point is that those 156 million Americans will go from currently from having their insurance paid for by their employers to having to pay increased taxes to pay for their insurance. Those 156 million Americans are going to be unhappy that Medicare for All shifts the cost of insurance from EMPLOYERS to EMPLOYEES. I, as a business owner, will love that I no longer have to pay for my employees health insurance. However, if you think that 2010 was bad for Democrats, wait to see what happens in 2022 after Democrats shift the cost of healthcare coverage from employers to employees. Keep your eyes on the goal of universal healthcare, NOT on any one plan for universal healthcare. Krugman's point is that there are multiple ways to get to universal healthcare, and some of them do not shift the cost of healthcare from the business owner to the workers.
5
In Australia we do have a 2 tiered system. Medicare will cover you for everything but you may have to wait for non critical surgery. GPs will clearly state whether they are free or you need to pay more. Essentially if you choose to pay more you won’t have to wait 30 minutes and can make an appointment.
My private health insurance (US100/month) will cover immediate surgery and picks up extras (with co-pay) like glasses, physio, gym membership etc if I paid a higher monthly premium I’d have a lower co-pay.
All Australians pay a flat 1.5% of their income for Medicare (no cap).
Certainly not perfect but no one goes broke or dies from a curable malady.
23
For the most part, Americans are more pragmatic and moderate than their politicians. They want health care available at an affordable price, but they don't have an ideological commitment either to socialised Medicare for all or a libertarian free-for-all. They just want to be able to take their kids to the doctor without going bankrupt. Is that really too much to ask?
13
The problem with all these different health insurance companies and plans is that they don’t get enough people, period. Under a single healthcare system, The Law of Large numbers will make our health premiums much, much lower if everyone is in one big pool. Both healthy and sick. Young and old. It’s a proven fact and it makes sense. It would also make it much easier to reign in these out of control drug prices with a single healthcare system. The power of numbers would force Big Pharma to the bargaining table. Americans don’t seem convinced that healthcare is a right and not a privilege. That’s a big problem and it’s a fallacy. Healthcare us a universal right and our current pay to play system only benefits the doctors, hospitals, drug companies, lab companies, insurance companies which are all out of control expense-wise. And the wealthy who can afford it.
5
Agreed.
One of the most purposefully misunderstood issues.
Medicare as the baseline option for all Americans is a great idea.
For those who want to see their doctor anywhere, anytime, private insurance or arrangements are not illegal.
For the poor, they will receive health care like every other industrialized nation on Earth, any so many that aren't, through Medicaid.
Health care merely administrates payments. The larger the number of people it represents, the better bargaining power it has.
We have a hodgepodge payment system of private companies, government payments, hospital write-offs and individual co-pays administered through a hodgepodge of for-profit insurance companies.
That is why the US pays 3 times every other country per capital in health care costs!
Innovation can go to the innovators, not those that buy up old patents and re-market drugs at 100 times the price for something else.
And there is no free market when prices are unknown, competition is non-existent at the service level, and billing is purposefully Byzantine.
Medicare as a baseline option for all Americans, paid for by a tax on corporations not per worker but on revenue, with options of better or lesser service levels is sensible.
It will help contain the outrageous costs Americans pay - 1/5th of every dollar of income.
8
This is exactly the sort of triangulating Clintonian Center for American Progress nonsense that Krugman always ends out trying to sell us on.
Employer-provided health care makes you a prisoner of your employer. I have employer-provided coverage. Its ok, but every time I need a specialist I have to find one that is in network. I had to see an out of town doctor a year ago for an emergency and I'm still fighting with my insurance company to get it paid. I'm less than thrilled about my dentist. And don't get me started about which completely arbitrary nature of which drugs are covered by my prescription plan and which are not. In spite of all of this I am terrified of going without it, which my boss knows and which consequently makes it much easier for him to say no to my request for a raise.
Medicare for All enjoys massive public support. So centrists have to pretend they want something almost exactly the same while running a whisper campaign to convince people that the government is going to take their coverage away.
Many people like their present doctor and don't want to lose them. That's what most mean when they tell a pollster they "like their current coverage." That's how I felt too until my favorite doctor stopped taking my insurance. The truth is that NOBODY likes their insurance company. Some are worse than others, but we all know that they are all rotten.
Medicare for All will be cheaper and better. The centrists need to get out of the way.
19
@Christopher According to the article, in the Medicare for America plan, individuals or employees could opt for Medicare. So, not a prisoner.
6
@Christopher: I agree with everything that you said. I too hate my insurance company. However, I wonder what the 156 million workers who currently have their insurance paid for by their employer will think when, the day that Medicare for All starts, the worker will have to pay increased taxes for their medical insurance. If you think that 2010 was bad for Democrats, wait till you see what happens in 2022 after Medicare for All shifts health care insurance costs from Business Owners to the workers. Keep your eyes on the goal of universal healthcare, NOT on any one plan for universal healthcare. Krugman's point is that there are multiple ways to get to universal healthcare, and some of them do not shift the cost of healthcare insurance from the business owner to the workers.
2
@ph1–MFA will be cheaper AND better!! No new taxes will be necessary. We currently overpay for health care for inferior outcomes, so we can spend less and get better results.
5
The debate needs to compare and contrast three major factors beyond the marketing slogans. Obama was not effective in getting the ACA solutions understood by the public at large. Which candidate can do the following.
Private insurance is profitable however the ACA regulated these profits and forced premium rebates when they exceeded the standard. IMO, the public assumes that insurance company profit is the major factor in the cost of health care. This number has to be put in context.
The overhead costs of the paper pushing between public and private systems is a black hole and neither side trusts the numbers. The numbers have to be agreed on and also put in context.
Finally, The cost of medical care (Provider salary, medicine etc etc ) has to distinguished from the cost of running the system. You are not going to cut these costs... at best you can limit their growth. So.... any discussion of new programs should compare and contrast how effective this cost control will be.
How you communicate on these issues is 100 % of the ball game. Keep in mind, the ACA implemented hundreds of cost saving methods and the public understood death panels and rationing. Obama could not do this... So there it is.. this is the challenge for all of the candidates.
2
I agree that an acceptable and workable system doesn't have to be Medicare for all. However, if you are creating some hybrid, how do you prevent lobbyists for insurance, pharmaceutical, and other medical industries from either:
a.) inserting poison pills into the legislation that will eventually make it fall apart, or b.) turning it into yet another form of corporate welfare or "public private partnership?" After all, any system that truly controls costs while simultaneously providing effective care for 100% of the population will mean less profit for some, who currently make massive profits by providing care that is drastically more expensive per patient to a more limited number of people. While most people see overpriced medical care and call it waste, fraud, and abuse, someone out there calls the same overpricing income. Waste and inefficiency is where the profit lies.
4
First Krugman writes, "an awful lot of reporting seems to be third order — not about the candidates, let alone their policy proposals, but about pundits’ views about voters’ views of candidates’ electability. It’s a discussion in which essentially nobody has any idea what he or she is talking about."
Later he writes, "But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress."
Whaddya know! A pundit's view about voters’ views of candidates’ credibility.
Doctor, heal thyself! (I hope you have insurance for that treatment.)
2
@GordonDR I don’t think credibility and electability are the same thing. For example, current POTUS.
3
Maybe we can try several options at the same time, by turning it over to our 50 national laboratories, the states. Propose funding measures, such as block grants, that the states could use to pursue the goal of comprehensive coverage for all their residents not currently eligible for Medicare. Then each state could try to achieve that by single-payer, or by private plans, or some combination, as they (and their voters) saw fit. Then we could see which method actually works best before rolling it out nationwide.
It seems to me that access to healthcare should be a right, not a privilege. In Australia we have a system funded by a 'Medicare Levy'. Not completely free but - heavily subsidised. You can also take out private insurance to 'top it up'. Not perfect, but quite reasonable.
We spend about half what the US does on health care. I think the reason is that our health industry is regulated quite strictly - as in countries with similar systems.
As Mr Kruger says, it is going to be interesting to see what the Democrats will cobble together - given all screams and pressure from vested interests. Best wishes for a good outcome.
5
Should point out that even the 'full socialized medicine' British system does not prevent private health care. You can still pay for it if you want.
5
Thank you Prof Krugman for weighing in on this important topic and for mentioning the dreaded “purity test”. Every time I hear that expression I cringe, because it represents a lose-lose for Democrats. Pass the test, alienate all conservatives and most moderates; fail the test, and disgruntled liberal purists vote 3rd Party or sit out.
I have empathy for the millions of Americans who suffer in our broken, embarrassingly cruel healthcare system.
But if Bernie doesn’t win the primary, and the purists sit out next November because our nominee supports meaningful reform that isn’t Medicare for All (“I won’t vote for a corporate shill!”), and Trump wins in 2020... where does that leave the healthcare system and those millions of suffering Americans? Would it not leave them 4 more years away from meaningful change that would have at least shifted what is considered “moderate” to the left, perhaps bringing us closer to Medicare for All?
I know that defending centrists is not fashionable in 2019, and understand that incremental change does not seem good enough given where we are. But I really believe the propensity of many Democrats (and virtually no Republicans) to not show up to the polls for candidates that don’t promise liberal holy grails (Medicare for All, Green New Deal, etc, right NOW!) will doom us to another 4 years of Trump and could undo 2018’s blue wave. Is it so unreasonable to try to secure Congress and the presidency first, then see how far left we can go?
17
@Concerned "Is it so unreasonable to try to secure Congress and the presidency first, then see how far left we can go?"
Yes, because unless the Democrats actually inspire voters, then they will not secure either of them. The broad outlines of the program will have to be clear to voters. We know what happens after almost all elections: back-room deals, in which the campaign donors get what they want. This is also why we need to elect Democrats funded by small donors.
1
@MAL - I agree that Democratic voters are not going to put blind faith in a politician with vague promises of a plan that will "take care of everyone" and "save a lot of money" like many Trump supporters did (nor should they). And yes, in the run up to the primary, I agree that we should carefully scrutinize candidates' campaign financiers, and I plan to vote for a candidate that has dedicated his or her life to serving his or her constituents, and has demonstrated that he or she has consistently acted in the interests of the American people over the interests of corporations.
But if the primary gives us a candidate that isn't Bernie -- then what? I'll want to see the broad strokes of a healthcare plan that moves us closer to one that looks like the rest of the first world, but even if I'm not thrilled about it, I'd never protest the election or vote 3rd party; whether or not it's fair, I'd feel complicit to a second term for Trump. I'll vote "D" in 2020, then vote for improvement in the 2022 Congressional primary.
I'd love to feel inspired by our 2020 nominee, but I'm not going to let perfect be the enemy of the good as long as we have this administration and Senate.
Employment-linked health insurance binds you to your job. If it disappears, so does your insurance. If you don't really like that job, you may hesitate to look for something else for fear of losing your insurance. It is certainly much healthier to be covered whomever you work for or whether or not you work or whether you are between jobs, etc.
7
@Alain
Why in the world should healthcare be linked to employment ?
We don't link the rest of our human rights to employment.
Besides, it artificially restricts the free flow of labor by chaining employees to the healthcare 'plans', it stifles innovation and entrepreneurship because people don't want to risk losing employer healthcare, and it puts ordinary businesses in the healthcare business, an unnecessary headache that businesses in Canada, Europe and Japan don't have to deal with.
In short, employer-sponsored healthcare is about as dumb an idea there is.
Better to be free in a foreign country than chained to an American employer healthcare plan prison.
30
What if the litmus test is not "no-private-insurance", but rather "no for-profit insurance", since no other major nation's health care system features this (even the linked Dutch system description contains the statement "Currently, there is a ban on the distribution of profits to shareholders."), and T.R Reid ("The Healing of America") pointed to this as one of the major reasons for our comparatively high expenditures.
9
@PC
Medicare as it is presently designed includes the possibility of private insurance either as a supplement or as a replacement (Medicare Advantage plans) that are offered by both for-profit and not-for-profit private companies. Why is is it necessary for a "Medicare for all" approach to change that model? Why not take the existing model and simply apply it to all?
5
@Dave—In order to not raise taxes you need the risk pool to include everyone. So MFA will not only be cheaper but better, so you start with the state employees with good benefits and employers like private universities with good benefits. Those employers will simply give their respective state Medicaid office the money they currently spend on health care. The state Medicaid office will be tasked with implementing the state MFA program. Once those people prove MFA is cheaper and better all of the other employers will sign up. No new taxes will be necessary because you just implement copayments and deductibles with CSR like in the ACA. Well off Americans are accustomed to paying copayments and deductibles so keeping those is much better than raising taxes.
Remember, MFA will be cheaper and better so the same amount we pay for health insurance today will cover 100% of the population under MFA...and it will provide better health care!
2
Speaking of all those workers with employer-subsidized health coverage who are "fairly satisfied," ask them again when the next recession hits. The last one, lest we forget so soon, saw 8.8 million jobs disappear and guess what? That wonderful, cheap company insurance went POOF along with the paychecks. Being satisfied with coverage is one thing. Having insurance you can count on through boom and bust is another.
94
@abigail49
Yes, and another issue is that many are satisfied with their employer-provided health insurance until they really have to use it. If you are relatively healthy and mostly need routine care and generic medications, most employer plans are fine. But if you or a family member gets an expensive diagnosis, you may find that out-of-pocket costs quickly pile up, especially if the medication you need is not in the formulary or the best specialist for your condition is not in your network.
19
@abigail49
Good points.
Also I question the "fairly satisfied" poll for several reasons.
First, it is a fact that that company medical insurance costs continue to rise, outpacing wages - has 'satisfaction' remained stable, or is it trending towards dissatisfaction as a result?
Second, in a system with only private insurance or private company insurance, what can it mean to ask if someone to gauge their satisfaction with their insurance? Satisfied as compared with what - with private insurance, with no insurance? So long as people are ignorant of healthcare for all alternatives, such polls are of limited value.
Third, polls show increased support for healthcare - possibly even among people who might, at the same time, express 'fair satisfaction' with private insurance. We need to see what happens to those private insurance satisfaction ratings as the alternative of healthcare for all is popularized.
8
@abigail49 People are always scared of the unknown. I, for one, would gladly give up my employer coverage to get us closer to health care for all.
2
About 12 years ago--I think before Obama was elected and definitely before the ACA was debated--Atul Gawande wrote one of his excellent health care articles in the "New Yorker" about how other industrialized countries with universal coverage ended up with the system they had. In every case he described, they built on what they had before to cover everyone. None completely threw out their existing system. Their existing systems were often a matter of historical accident, but they all took a practical approach and built on what they had. So there are multiple models out there that work better than the U.S. model. From single (government) payer & private providers, to almost all government providers, to a mix of public & private providers and public & private insurers. One reason other mixed public & private insurer systems work so much better than ours is that the private insurers and providers (and drug sellers, for that matter) are much more tightly regulated than our private insurers and providers. I'm for any system that will work better than what we have and agree with Krugman that it would be counterproductive to make any one approach to achieving universal, quality, affordable care a "purity test."
36
@Paul
Not altogether true Paul. The UK threw out their old system and adopted NHI in 1948, when the country was in tatters, to help compensate for hardships during the war. It's called the Beveridge Model, named after the Brit who designed it. All other countries who have since adopted that system (Spain, Norway, Sweden, New Zealand, Hong Kong, and Cuba) had to ditch their old systems to build their versions of NHI. And they all work a lot better than ours does.
Joseph in Missoula
1
@Paul The USA already has Medicare for the over 64 population (serving 18%) and Medicaid (another 20%) for those under certain income levels. Extending these to cover all of the population would not necessitate completely throwing out our *existing system.* Such as that is. Please try another health/insco talking point.
1
@Joseph
Actually, Gawande used the UK as one of his primary examples. Their accident of history was moving a lot of medical professionals out of the big cities to more distant locales when they moved a lot of their children there to escape German bombing. The government established medical facilities and hired medical professionals to move these locations thereby providing a basis for a government-run system which they could build upon to establish NHI.
Make all the insurance companies 'non-profit'. Allow them a 3% operating margin, and supply careful, strict, and diligent regulation. Health care should not be a 'profit center'. Offer a public alternative, with a suitable tax rate for the covered who make that choice, and their employers required to increase their pay by the amount that private insurance's premium would otherwise be. Tax any surplus to the employee as ordinary income. Phase this out over 20 years.
The US doesn't have to invent a totally new way of providing universal high-quality health care. Plenty of other countries already do it... study them all, steal their best ideas and combine them into a new way for America. Spending 18% of GDP on healthcare (and growing) no longer is sustainable. We aren't getting what we're paying double for... other nations spend lesser percentage of GDP for better outcomes across a broad spectrum of health measurements. Where is "American exceptionalism" - unless we get to be 'the exception that pays much more, for so much less...'?
4
"So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins."
I heartily agree with Krugman on this and the answer is obvious. If the Democrats can win the Presidency, they can reinforce the ACA in a hundred different ways, an ACA that has already actually passed Congress (and only barely during a period of reaction against Bush's Iraq War).
Frankly, the only person who benefits from "Medicare for All" is the person who has taken it on as his campaign slogan, Bernie Sanders. I must have heard Senator Sanders asked 10 times how such a plan would be implemented and how much it would cost in taxes, and how people who already have a private health plan from work would acquiesce (or not) and NEVER have I heard him provide a coherent answer, this after years of ballyhooing it, of seeing just such a plan crash and burn years ago in his own state of Vermont.
Allow Senator Sanders to undermine the ACA with his fantasy bromide and you'll foolishly be letting the perfect destroy the good.
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@GED
Not necessarily. And politics is like war, it isn't about playing it safe. In the meantime, there'll be many months of bully pulpit education opportunities for all the candidates between now and Summer 2020. Lots of minds can change between now and then. The conversation will be one we need to have. That said, you may be right, although at this early stage, you shouldn't be so certain that you are right.
Joseph in Missoula
1
I like Mayor Pete's formulation: Medicare for all who'd like it. Doesn't take anyone's current plan away from them. More likely to pass Congress. And a good way to find out which approach works best. If it's Medicare, then over time it will come to dominate. Smart guy Mayor Pete.
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Pete!!!!! I will be voting for him in the primaries, should he make it that far.
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"To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All."
There should only be ONE program that EVERYONE, including the politicians, should be required to be a part of. That way, they, the politicians, will have an incentive to make it work, because they will be the recipients of that care. If the rich and powerful can buy their own health plans, they will have no incentive to make "Medicare for All" succeed and will continually try to starve it financially just to prove it doesn't work. Just look at what Republicans are trying to do to Obamacare.
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AOC doesn't have to get it passed. Taking a nationally unworkable position keeps her on magazine covers and headlines.
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Beto has endorsed the Medicare for America plan, and I thought a couple of other candidates have as well.
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Not sure which the answer is although I favor a universal care for all. But one thing must be said: people believe that in USA the private health system works and fast. Well in my experience direct and indirect this is not true.
Personal, between a tel call and the doctor first visit elapsed one month and a biopsy was taken. The diagnosis was a non melanoma skin tumor. Between the answer and the removal of the tumor it took exactly three months.
Non personal: macro hematuria (visible blood in the urine), in November; between various visits and exams (one -two months between exams) the final diagnosis has not been established yet.
Is this fast health care? no, but is very private.
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American Courts have ruled that the States must provide education for all children of permanent residents, whether they are legally permanent residents or not.
This is broadly accepted now as necessary public policy.
There is every reason to believe that the Courts will similarly rule that any kind of universal health care program must include all permanent residents, whether they are legally permanent residents or not, for similar reasons.
It is just unrealistic to provide medical care for all legal residents
and exclude residents not here legally.
No advanced country does that for obvious political, economic, heath, and humane reasons.
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@David -- How about this: anyone who pays taxes to US governments deserves to have education provided for their children, "whether they are legally permanent residents or not." American courts have ruled this to be the law...
When a universal health care system is established, the same criteria must apply. Anyone paying taxes gets coverage, "whether they are legally permanent residents or not."
Anything less is inhumane. We 'cover' them now, when they show up sick, bleeding, or dying, at Emergency Departments now. And all those costs are imposed on everyone else's payments - the care isn't free even though they don't pay. Uninsured people are free riders - the only solution is universal coverage, and universal payment through taxes.
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@David
Not true. Canada, for example, provides universal healthcare for all citizens, but non citizens, whether legal residents or not, must purchase private health insurance. They are not covered by the government paid healthcare.
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@Jim Brokaw
We need to be honest with ourselves in considering all immigration policies and medical policies and costs, all residents, legal or not, are going to get full benefits.
It is the only humane and practical policy.
What is wrong is in describing any of these programs as only for those who are permanent legal residents, when that is not going to happen.
People in a liberal democracy such as the USA need to know honestly the full costs and benefits of any of these programs so that they can make informed decisions.
Describing them as only for legal permanent residents is cruel and undermines our democratic right to know the real facts.
"Most of these people are fairly satisfied with their coverage." Most? What does that mean? 25%, 45% ( /-) of the 1\2 of Americans who receive employer coverage? Whatever the precise number add it to the other 1\2 where their jobs offer no health insurance and that's an awful lot of dissatisfied voters!
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@Marshall J. Gruskin
Right now in Massachusetts 97% of residents are covered—Massachusetts could start a Medicare for All program tomorrow starting with state employees and employees at the universities. So they simply give MassHealth the money they were paying for their employees’ health insurance and MassHealth runs the state MFA program.
Once the state shows they are providing superior health care for cheaper GE will hop on board, and shortly thereafter all of the other employers—what employer doesn’t want to save money?? Then Massachusetts would get waivers from the federal government to offer their MFA program on Medicare Advantage and the ACA Exchanges. Boom—Massachusetts MFA 100% covered for cheaper than the 97% and it is BETTER!
2
Dr. Krugman’s description of Australian health care as “single payer” is not entirely accurate. True, there is a government program that covers everyone, but its benefits are limited and there is a robust private market in health fund cover that supplements government cover, primarily for hospitalization. There are tax incentives for people to but the private cover. This is an important point, as it shows how a government program can coexist with private cover. A model of limited government safety net cover and optional purchase of private cover is a way to provide universal coverage without shutting down private insurance.
5
Private supplements coverage also exists with Medicare in the us. This is exactly what krugman is talking about - nobody has any idea what they are talking about. It was silly to ever suggest that there wouldn’t be a private market!!!
Opinion. throw the bums out crowding his way, and elect Bernie Sanders. Centrist front runner voters and progressive policy voters meet in the middle, and there's no need to talk about anybody being too afraid of full health care coverage to vote for their own interests, if a candidate with experience has a million boots on the ground to explain it to them without waiting for a media to. When what we are really a saying is that we do not think that they are up to the task.
2
All this is why in 2008 / 2009 I felt our best approach would have been a Medicare -like public insurance option. Private insurers would then have had to compete on both price and quality with the public plan - a contest they were bound to lose. I suspect we would have been almost to Medicare-for-all by now. Too bad we thought was too impractical then.
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@bruce Lieberman single-handedly blocked the public option. Pelosi had passed it out of the House. Democrats had 59 votes, and needed to get Lieberman on board to get to 60.
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Yes, exactly. I'll never forgive the Senator for this; but consider how many insurance plans are headquartered in Connecticut.
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@bruce - this is the way American government works...
“And most of these people are fairly satisfied with their coverage.”
I would appreciate some additional information to support this frequently cited claim. The distinguishing features of profit-driven health care are exorbitant premiums, deductibles, and co-pays; delays and denials for tests and treatments; confusing and sometimes deceptive billing practices; medical bankruptcies; and millions uninsured or underinsured. The endless complexities of health care in America compound rather than alleviate the suffering of patients and their families. Are large numbers of people truly “satisfied” under this system?
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I should also have included in the list of features the narrow choice of doctors available, given the restrictions of the network system.
@Ann
Many are, because they haven’t been faced with a serious, expensive illness. If all you need is basic care for routine problems like the flu or getting your kids immunized, most employer-provided plans are fine. Unfortunately you don’t find out how inadequate your insurance really is until you really need it.
Adjectives are not a substitute for thought.
Yes, the Electoral College needs to go. And while we’re at it, let's revamp or get rid of the Senate. North Dakota, with about 750,000 residents, has the same number of senators as California. How does that make any sense?
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@Jeff Burger—We have 2 Dakotas because Republicans wanted more senators to keep their boot on the neck of the South. In fact the last 4 states were admitted to the Union only after existential threats forced our hand to give them statehood. So the Mexican Revolution forced the Senate to admit AZ and NM and the Cold War AK and HI. So the Senate was the most important federal body from 1865-1932 and the North/South issue prevented progress because neither side wanted to add senators that would end up siding with the other side.
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@Jeff Burger FYI, my comment above was a reply to Jamelle Bouie's column, not to Krugman's. Not sure how it wound up here, but can it be reposted there? Thanks.
@Jeff Burger You could combine Idaho, Montana, North Dakota, South Dakota, Wyoming, and Nebraska into one big state and it wouldn't even crack to top ten in population. It's nuts. The founders couldn't have anticipated this level of uneven population distribution when they devised the Senate. Something must be done.
Nobody talks about this, but employer provided health insurance is the primary reason people over 50 can't get hired. The largest employers are self-insured. They directly pay for the healthcare costs of their employees. They may use an insurance company to manage it, but the company pays for it.
This creates a tremendous financial incentive for large companies to only hire young people. Health problems become much more frequent when we get past 50, especially past 60. Even though, many if not most of these people possess a world of experience and would be excellent workers.
It therefore, would be better for an aging population, which we are, to have health insurance stay with the person and not the job. This also would greatly benefit entrepreneurs. The risk of going out on one's own is great and the prospects of doing so and having to pay for massive premiums prohibits many from taking the plunge.
So whatever we end up calling it, we need some kind of insurance that stays with the person. So long as we hold to company provided insurance, we will be locked out of real reform. This change can happen incrementally, and probably should for political expediency.
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@Bruce Rozenblit I agree with this comment with a caveat; we need to look at our health care system to find out why it"s so expensive more than any other 1st. world country. Our infant and maternal death rates are shocking! We then can discuss how we want to pay for our health care.
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@Bruce Rozenblit
Thank you. This is a very Important point, and why one possible incremental option would be to propose just dropping the Medicare eligibility age to 50. Those covered by employer plans that are at least equivalent to Medicare could stay in those plans (just like those eligible for Medicare now can do), but those who are not eligible for employer provided insurance could sign up for Medicare instead. That would address the most vulnerable population, possibly reduce the reluctance of employers to hire them, and also likely reduce the cost of ACA plans by getting more of the older and sicker population out of the pool.
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@Bruce Rozenblit
I totally agree. Change needs to be implemented incrementally. Bernie and the rest may think it sounds good to amputate our current system of healthcare insurance, but realistically, we are not going to eliminate or radically adjust such a large segment of our economy in a single fell swoop irrespective of some people's beliefs.
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Mr. Krugman is as usual spot on. The medical care plan that will pass Congress and be accepted by most of the people is the one that will serve us. If a plan can not meet this criterion it is no better than the paper it is printed upon. (These old sayings probably don't mean anything if you don't remember paper but perhaps you know what I mean.) If Democrats become like republican ideologues who will not consider every option available we will become as useless as the GOP which has not had a useful idea in decades.
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I have employer sponsored health insurance along with the obscene yearly deductibles.. It is not health insurance. It is catastrophic health insurance. I would drop it tonight in favor of Medicare.
One of the few advantages of growing older is getting closer to Medicare eligibility. If it is good enough for those over 65 it is good enough for all Americans.
Sorry, Krugman. No more slow walking and baby steps. Medicare for All. Now.
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@Concernicus Don't you think the republicans and the other side have a say on this?
@Ni Daye At this point they certainly should NOT have any say. In anything. Period.
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Anyone trying to set up single payer or what ever needs to look very closely at who is paying and who is trying to edge their way into taking control. This seems to be a country where greed is rampant. IE, prisons. Who is going to be the oversight for the endeavour?
As a foreigner, I am use to single payer and loved it. I no longer have it while I remain here. Some day maybe Amearicans will come around to realize how archaic the healthcare system is here.
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Dr. Krugman still does not understand why Clinton lost to as flawed a person as trump. Or why she almost lost the nomination to a person not even in her party, and so widely dismissed as a threat that the party decided to let him run anyway. Perhaps some day he will.
Obama had an opportunity to effect real change, but blew it by not holding anyone accountable for the fraud that caused the Great Recession. He got a lot more Americans insured by a dusted-off corporate-friendly Republican proposal, and that’s something. But much less than Americans outside the corporate-employed upper 20% deserved and hoped for when they elected him.
Clinton, or any of the conventional Republicans that trump trounced, would have been defeated by any dog catcher that didn’t shill for corporate and other moneyed interests that control Washington.
I don’t think for a minute that Democrats are going to nominate someone who fails to make it crystal clear that they understand America needs RADICAL evidence-based solutions, and has what it takes to fight for them. The next election will not be won by an incrementalist who promises no more than a return to conventionalism. We’re running out of time before America’s decline can be reversed, and the rest of the planet with it.
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Agree 100%. I've been more or less a strident proponent of Medicare for All, but am recalibrating my views precisely because I think advocating for forcing people off their employer plans would be a death knell for the 2020 Democratic nominee.
From what I've read, private employer-provided health insurance often leaves a lot to be desired if one faces a real medical emergency. Those GoFundMe accounts one sees all over social media aren't all uninsured people.
But most people aren't facing a real medical emergency, and are satisfied with the private plans they have. As Krugman points out, it's going to be a very tough sell to get them to ditch their plan for a government run insurance plan the details of which are still unknown. If the Democrats run on such a proposal, the odds are they will lose the election.
Medicare for America is essentially the public option that Obama had initially wanted to include in the ACA. If such a buy-in plan is successful, private insurance will either need to adapt to compete with the public plan, or disappear on its own.
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@Vin No one would be "forced off their private plans." People could still overpay for those, if they wanted to. And as for being "satisfied" with those plans, I can tell you that I am not, even though I haven't faced a major medical emergency, but am terrified that I could. I also see what I pay each month in premiums -- that is, why I and my co-workers receive minimal increases in actual salary. And even if it takes a couple years for people to leave their private plans, what's the harm in that?
I share your concern about any "litmus tests", but not just about Medicare For All. In the end, the Democrats must not cannibalize themselves as they've done so often in the past. They must rally around the idea of winning.
However, as to your idea that we should continue a for-profit healthcare system - because that's what the Dutch model you tout really is, and what the ACA is - I disagree.
You also make some false statements about Medicare For All. First, if it truly opens Medicare as it currently exists to everyone, then there will be a Part-A that everyone gets for free, and which covers much of what's considered basic care. Then people have the option to buy a supplemental, Part-B, plan that's provided by private insurers, but under government oversight to ensure uniformity and low cost. So there IS an option for people to get more comprehensive coverage.
You and others toss around this 156 million people who have coverage from their employers as though they're all happy with that. Many are not because they don't get this without paying some kind of premium, and for smaller companies this can be costly, for lesser coverage. These folks may well jump at the chance to have better, cheaper coverage.
And you assume that Sanders, Warren, and others won't make it plain what the NET cost to people will be when comparing how much their taxes MIGHT go up vs. no or very low premiums.
The ACA was a cave-in by the Dems. They must not make that same mistake again.
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@Kingfish52 "The ACA was a cave-in by the Dems." This comment is exactly why Krugman's essay is needed. The ACA passed by a single vote, and only exists today because a conservative justice surprisingly switched sides to preserve it. The notion that there was a "cave," and all we had to do was propose and push through s more thorough healthcare overall, is a fantasy version of history. The country may be more ready for the next step than in 2010, but I have a real concern there will be no step at all.
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I agree that we should not put taking away company sponsored health insurance on the table. Fix the ACA and open up Medicare and Medicaid for people (like me) forced into "early retirement" or other situations. Let's not overdo what can be achieved or "easily" communicated.
6
I paid into Medicare with every paycheck for almost fifty years, so I own the term “entitlement”. I had continuous employer-based insurance during those years. When I reached 65, I enrolled in Medicare Part A, which costs me $465 every three months, plus I pay a little more than that for a (Plan F) commercial supplemental to cover the 20% gap, and nearly $30/month for a Part D drug plan. My husband pays the same amounts for his coverage.
As a retired couple, our annual out-of-pocket is nearly $10,000, after paying into the pool all those years. Our last employer reimbursed us that first year, and when we retired at age 66 we made sure we were prepared to shoulder the cost. I discuss health care with people all the time, and get the impression that many think that if they can just make it to Medicare, they will have very little financial input for their care. In fact, beneficiaries face costs like my husband and me.
One of the details of so-called Medicare-for-all I can’t grasp is what will be the quarterly premium for people who haven’t paid into the system for decades? It would have to be higher, with continued withholding plus premiums, right? Like they misunderstood the ACA, many people somehow expect to pay much less for insurance coverage than is possible. How can we fill that knowledge gap with facts that transcend politics? No Mandate and No Medicaid Expansion almost killed Obamacare. Expectations are unattainable, mostly because Republicans continue to lie.
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@Alice Smith
Medicare is based on taxes paid through out one's working life - I also have wondered how much Medicare for All would cost those new to the system? And how would their families get coverage? Lots more to know about these plans before any decisions (and litmus tests!) are proposed and acted on.
@Alice Smith, Medicare Part D was only created 15 years ago and it is paid out of general revenues (paid mostly with deficit spending, in fact). So no beneficiary has really paid for the benefit. The "Expanded and Improved Medicare Act" would significant reduce existing co-pays and deductibles to a nominal amount -- more in line with other developed countries. In terms of expanding coverage, we would actually end up saving money over time, because a universal system would have a more efficient payment system, and would have lower administrative costs. The single purchaser would also have more leverage with providers and suppliers in the same way that Wal-Mart and Amazon do. e.g. at least one conservative estimate is that we would end up saving $2 trillion over the next decade by enacting the "Expanded and Improved Medicare Act". We're estimated to spend $34 trillion in total expenditures over the next decade with the existing patchwork system (including both public and private money), versus $32 trillion in total expenditures over the same time period with a streamlined universal public insurance system (with mostly just public money). Under the Expanded and Improved Medicare Act you would pay less. The big challenge is actually making the bill become law, because industry groups are understandably not enthusiastic about losing out on $2 trillion in revenue and profits over the next decade.
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@jleeny - Sorry - make that "purity tests".
So I went to the link provided for Commonwealth Fund rankings, and U.K. was rated #1 overall, Australia was #2 and Netherlands was #3. So I am sure why Prof. K says that “the Netherlands actually tops the Commonwealth Fund rankings.” Not true. I trust Prof. K to do better. But he is right about his overall points. Essentially every other developed country has some for of universal healthcare and essentially every other country does a better job of efficiently using its resources for healthcare for its entire population and with better healthcare outcomes than in the US. The US has great specialized medical care for those who have access to it and for those who can afford it. However, for most Americans who get their healthcare from an employer funded private insurance, if they lose their job, they quickly discover how fragile their healthcare coverage really is. And even if they have insurance, it is virtually impossible to know how much real coverage someone has until they get sick.
As Prof. K says our best option - in terms of political reality - is to transition to an improved version of Obamacare with a public option and allow people to keep their current employer based insurance and doctor network if they want. Remember 40-45% of this country are Trump supporters i.e. they have lost their minds, but they vote in Senators and Congressmen that will never support Medicare for All. They oppose an improved Obamacare also, but that will have a better chance in 2020.
5
Government-run Medicare For All has some big advantages over a hybrid public-private Medicare For America plan.
No more "open enrollment" each fall when you have to review what's changed with your employer's plans. MFA covers everyone for their entire life. No more worry about having to change networks and doctors. No more worrying whether your plan covers all your health needs.
No premiums, co-pays, and deductibles, which change or go up every year. Taxes for MFA will be fairly predictable and constant.
No more worrying about having to get new insurance if you leave or lose your job.
No more unexpected medical bills.
MFA shouldn't be such a hard sell. People are concerned about cost and coverage. MFA, if done right, can improve both.
4
While I agree with Dr Krugman’s main point in this article, I would like to point out that we in Australia do not have a Sanders-style Medicare-for-All system - private health insurers are a major component, so much so that the federal government provides billions in direct subsidies for people to have private health insurance, while also making higher income earners contribute more in our Medicare surcharge if they don’t have private health insurance.
My family and I pay over $7,000 a year for our private insurance (after we receive our subsidy) and this is what we have always used for surgery/hospitalisation, as there have been minimal gaps (mainly for anaesthetists) and the care has been provided much earlier than it would have been provided in the public system.
Am I happy to pay three times - Medicare, private health and then gaps - for health care? Not really but I’ve lived under an American style system and I’d choose our system everyday of the week and twice on Sundays.
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WRONG PK...when we returned from Europe 20 years ago monopolistic healthPROFIT, U.S., had not yet taken effect. We were fine with employer provision. Today, not at all. So many asterisks have been placed charges are indecipherable, costs are horrendously expanded, and deductibles are outrageous.
As my wife is nurse, Europe, we know exactly what comparisons healthCARE entail. Germany, where we lived and will return, has both private and single-payer systems, but both use public-government hospitals for emergency and operations. Largest problems with government sponsored healthPROFIT, U.S. will be use of facilities-hospitals single-payer, and domination by insurance companies which are banks.
Single-payer is far preferable, but choice of private access needs be continued for those desiring.
3
First, I think the government needs to make private health care companies provide people with sufficient data to make informed decisions and comparisons. It is too complex to understand the costs for different insurance companies, drug prices, and hospital procedures. It's also a challenge to understand if there is fair competition between health care companies in the regional marketplace. It seems as if people do not have many choices. I think the candidates have to provide details and must show their plan will lower health care and prescription drug costs. The plan should create an incentive for health care companies to care for their patients; they should not make more profits when patients sick or injured. My employer pays a substantial amount of money directly to my health insurance company, otherwise my healthcare would be unaffordable. Companies that pay for their employees health care have an incentive to take care of them, but it seems as if at a minimum, people should get a tax deduction for their own health and dental care, and you should not have to rely on your employer to pay your insurance company. If companies did not spend so much on health care for their employees, maybe they could pay their employees better wages or hire more people? I think some big corporations, like Amazon, are planning to lower health care costs by hiring their own health care providers. It definitely needs more discussion! Thanks Professor Krugman!
1
The first chance employers get to rid themselves of employer health insurance plans they will do it. Medicare for America will morph into Medicare for all in a short period of time; unless there is a penalty for employer sponsored medical plans to drop the plan as a consequence of Medicare for America.
2
What has been the trend for the number of Americans receiving health care via their employers? PK says it’s currently 156 million. What was it 15 years ago? A higher number? Of that 156 million, how many are financially strapped by the annual costs and/or have a high deductible policy and would be better off with a single payer type plan? That data will help steer the Dems toward a real healthcare solution for working families.
Most importantly, any other healthcare system would be cheaper, better and cover more people than the current Great American Healthcare Rip-Off.
Every other rich country in fact has cheaper and better healthcare that covers everyone in their country.
One can always find anecdotal evidence that America has the 'best' healthcare, but that myth is belied by the tens of millions of Americans that the system abandons through complexity, sticker-shock syndrome and lack of access, as well as the additional tens of millions the American system underserves for the very same reasons.
Country and % of GDP spent on healthcare
United States 17.2%
(Every additional 1% of GDP in the Great American Healthcare Rip-Off represents a $200 million surcharge that Americans pay annually versus other rich countries; i.e. based on our GDP, our 'free-market' system is essentially $1.4 to $1.6 trillion more expensive than the superior Dutch, British and Australian systems.)
Switzerland 12.3 %
France 11.5
Germany 11.3
Sweden 10.9
Japan 10.7
Canada 10.4
Norway 10.4
Austria 10.3
Denmark 10.2
Netherlands 10.1
Belgium 10.0
United Kingdom 9.6
Finland 9.2
Australia 9.1
New Zealand 9.0
Portugal 9.0
Italy 8.9
Spain 8.8
Iceland 8.5
Greece 8.4
Chile 8.1
Slovenia 8.0
Korea 7.6
Israel 7.4
America has the worst that the rich world has to offer; lousy medical care for close to twice to price of a decent civilization.
All because of unregulated Greed Over People.
D to go forward; R for more medical rip-offs.
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@Socrates Yes, this is finally the question that has to be answered, What does private insurance provide at all that we cannot provide through government? The question about being satisfied or not with employer-based plans hides the question of what insurance companies provide. An employer of sufficient size could be self-insured, as many local governments are, for example. So that is the question, why do insurance companies merit any slice of the pie whatsoever?
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@Bob Marshall
Bob, it's unbelievable that private insurance companies actually profit from healthcare. Their bottom line increases at our expense in the form of higher co-pays, higher deductibles, and lower coverages.
And so powerful are the insurance companies, that Obama had to cave to them and give up the public option when he was doing Healthcare.
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@Nightline
Obama negotiated with Republicans. That was his problem. Then none of them voted for the compromise he had made to get their votes. (Then he kept negotiating with them about many things, with similar results.)
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Virtually every day there are two or three opinion columns that are basically “Democrats should not pursue policy X.” Of course only a few years ago, I recall the same columnists denouncing a public opinion. The idea of a “purity” test is childish. The reason people are confused is that Medicare for All is really popular, but most candidates decided just to adopt similar sounding plans without the substance. I’m very skeptical about people being satisfied with their employer based coverage. I can name one person I know that likes their health insurer. Also, this is an idiotic line of argument: employees may like their coverage but it changes year to year. And all the jobs I’ve ever had that provided coverage went in one direction: cutting benefits and shifting costs to employees. Insurance companies do not provide any value. They make money by denying healthcare, period. Plus the Jayapal and Sanders bills have comprehensive coverage. The people that talk about Medicare for All being problematic or not feasible should read news clips from the period Medicare was first proposed. They are the same. The people that argue against Medicare for All, don’t apply those arguments to Medicare. The problem is most media companies from the Washington Post (Amazon/Bezos) to MSNBC & Vox (Comcast) to CNN (TimeWarner) are heavily invested in for-profit healthcare ventures but never disclose those conflicts of interest. Large corporations generate news in favor of corporate interests.
7