We are often reminded of how much of every "healthcare" dollar is spent on not-healthcare, of the jaw-dropping trillion or so that goes to red tape and paper shuffling. But there is another cost that goes unmentioned: the hours and hours that consumers spend wrangling with customer-service people on the phone and each year on "choosing" a plan: "Hey dear, do you suppose one of us will come down with cancer this year? Think not? OK, we won't purchase that coverage. How about for a bad reaction to a bee sting? Or ...?"
It's something out of Theater of the Absurd.
19
Conservatives support a military because they feel that's one area of service that the market can't efficiently and properly achieve it's objective. It's not been much different in health care. Capitalism has been spent too much without achieving a commensurate amount. If we didn't already have the Government in healthcare (Medicare!) I'd understand if allowing the public option is a radical change. It's not.
11
As the article shows Obamacare with Medicaid expansion helped to insure some 10% more Americans. If the Republicans were less uncooperative, most Americans who needed coverage could have been covered.
So many things need to be achieved to be halfway closer to other developed countries. If Democrats are laser-focused on improving healthcare, without becoming too aggressive, a lot can be achieved.
1. Reducing the price of prescription drugs: Here Republican cooperation is easier. Bernie Sanders's plan https://www.vox.com/policy-and-politics/2018/11/20/18104560/bernie-sanders-ro-khanna-lower-drug-prices-bill-trump could get Republican support, probably if amended.
2. Medicare for All maybe a pipe dream now. But there's nothing wrong in passing a legislation in the House, more like "a Demonstration, a Rally" to bring attention to the public, and then conducting nationwide town-hall meetings. It may take a few years but eventually it can be achieved when the public becomes convinced that a Single-payer system like Medicare for All is actually far cheaper than the current system where
millions are left out and tens of thousands die unnecessarily from lack of health insurance.
14
New Jersey’s failure to comply tax (a.k.a. individual mandate) is going to drive young, healthy people to leave the state. The sick and disabled will stay. The only reason New Jersey even has population growth is because it’s cheaper to live there than in New York City. But, this is changing. New Jersey’s population growth has already slowed to a crawl and will start going down because of un-American laws such as that.
2
Yea, people choose to leave a state because too many people have insurance. Not hardly.
2
That was a very good idea to devise their own public health programs to cover people's health needs. What if the states decided to devise a multi-state plan to gain further economies? One might argue the Federal government regulates interstate commerce, but what if states proclaimed states rights to cooperate in a pooled program? It would require extensive law resources to win the power of self regulation and the rights for states to cooperate, much like the port authority cooperation between states.
2
For years, the Republicans tried to repeal the ACA thus taking away people's health care in effect. That would have resulted in thousands of unnecessary deaths and much suffering.
Think about that.
3
If you read the doctors' comments here - in the Times Picks for example - different problems with healthcare are identified. Of course, even though you are right in the middle of the healthcare delivery system as an MD, your perceptions are somewhat subjective, just like everybody else's.
One doctor says overconsumption is the problem. But it seems like what he is talking about is the fact that in general most of our healthcare dollars are concentrated on providing extreme levels of care in the end-stage of diseases. We let people get sick by providing no preventive care - or maybe no care at all to the uninsured - then pile on all these services when it's too late to do anything. That's not exactly overconsumption though. That's misaligned consumption.
Another doctor says the problem's profiteering. And when you look at costs vs. outcomes in Europe, that seems closer to reality. A lot of these American home truths - "efficient markets" and "supply and demand" "overregulation"- don't really apply to people who are seriously ill, dying, desperate, and need care.
The sick are being exploited for profit while our Republican lawmakers look on - callously - and block or sabotage all efforts to improve the healthcare delivery system and infrastructure in the US. But they've got money, government-sponsored health insurance, and time to kill.
The problem is, people are also getting killed by substandard healthcare or no healthcare in the US.
12
The Democrats will put real solutions on the back burner. Why? Healthcare lobby money is to lucrative to just give up.
5
A large minority of Americans resent the government forcing them to buy health insurance on philosophical grounds alone, and philosophy is more important than economics to the working class. Just ask your plumber about it if you have any doubts. Regardless of the costs or benefits, if the Dems manage to re-impose the Individual Mandate, a great number of the working poor will once again vote for whoever promises to free them from this obligation.
So, hooray for NJ, but other states must be allowed to continue wallowing in their misguided stupidity should they so wish.
Quick, someone tell Nancy before she leads us into another ten years of oblivion.
2
@kbaa What your plumber wants is the Democratic protection for those with preexisting conditions and the GOP elimination of the mandate. In other words, a free lunch. Don't we all!
10
Wonderful (sic). Just what we need, 50 different medical programs, 50 different bureaucracies, 50 different fiefdoms with 50 different biases which will work as well as 50 different voting systems.
If America is to compete with China & Europe, the federalist system conceived in the 18th century needs to follow the DoDo bird into extinction.
We need ONE health care system that applies to all Americans and as a former marine, I see no reason to duplicate our to-be-created Universal Health Care system with a separate VA system and it's bureaucracy.
95% of veteran medical problems are no different than the rest of America.
Allow the ONE system to negotiate with drug companies and the savings will be huge.
8
It all boils down to capitalist monopolies who enrich themselves off an ill served public. So many countries have some form of universal healthcare that I do not want to hear that it can't be done.
Those who are not intent upon making healthcare work in America are either profiting from our awful system or inculcated by corporate driven propaganda to believe 'socialised' medicine will lead to death camps.
Let's make it work for all. Down with capitalistic greed.
6
Pushing for Medicaid expansion at the state level will make ObamaCare much more effective.
4
“Democrats need to have a positive agenda, not just be against Donald Trump.”
Yes! This is the most tiresome bit of fake criticism. It is what people trot out when they are too lazy to actually come up with policy-specific criticisms for the Democratic Party. It is a hood-wink and a gimmick, with no reference to specifics or facts, relying on its inherent vagueness to make it hard to refute.
The Democratic Party is hardly beyond reproach, but this one is pure nonsense. It is what people say when they have nothing positive to contribute to saving this country, but just want to sound wise and sophisticated.
2
I have no problem with that.
Paul, youse right about dis....
If we let the poor states continue to deny care to their denizens, the gap in lifespan will become obvious. It's already over 5 years now.
And blue states can't brag too much, since they live 5 years less than citizens in many other countries.
1
Even though the repubs don't like it, some version of universal healthcare is in the cards. This is good: they will have to spend their time going after Social Security, Medicare, Medicaid and Universal Healthcare. Maybe the next step should be a universal living wage. Just another block in the foundation of the American commitment to acting like we who we really are.
1
I see no possibility of Obamacare surviving in its current form. The reason is obvious to me. A person with a chronic health condition is able to sign up for Obamacare to manage his healthcare costs, while a healthy person is expected to pay the same or more for his insurance. At some point, the healthy person is going to say he’s not interested in doing that anymore. He’ll protect his wealth from creditors by putting it in a 401K, IRA and his home’s equity and then go without health insurance.
3
If in addition, one wants to minimize gun violence and Mass shootings all one has to do is adopt Massachusetts laws which has the last gun violence of any state. Good luck on this one.
I would like to understand how it might help or hurt to take health care out of the hands of private insurance companies. Lately, I got a bill that puzzled me. A certain amount was deemed "reasonable". My insurance wouldn't pay the amount beyond that. Who decided what was "reasonable"? How much did it cost for employees to decide what is "reasonable" and tell me how much wouldn't be covered? Why should I pay the amount beyond what was "reasonable"? This feels like a black hole. Once I meet my deductible and pay copays, somehow, there's more.
Would Medicare for All take private health insurance companies out of the picture? If not, why not? If so, how much money could be saved by removing those middlemen?
Part of setting the stage for 2020 is helping the public understand what the different options might entail. I look forward to reading articles about this.
8
Always read any fine print at the bottom of any Evidence of Coverage (EOC) document, and the definitions at the start of the full document you get in addition.
Also, a lot of insurers are using “narrow networks,” and/or Regional Based Pricing these days. That means that nope, you can’t go to any doc, and that they’ll pay only up to a general average for some procedures.
Sorry, but there are very good reasons for this. Mostly.
1
@Robert This 91-year-old Democrat is SO glad he has Medicare. I don't know anyone who has Medicare who isn't happy with it.
11
Only one of the following two examples can illustrate the inalienable right to life, liberty and the pursuit of happiness:
1.) The right to "ëarn" obscene profits and executive salaries by insurance companies, big PHARMA, medical equipment companies, hospital corporations and some physician groups; or
2.) The right to life saving and health improving health care for all.
America has chosen. Let us change.
1
The best thing for the house to do is pass legislation that helps all American's and force the senate to vote so their position's are clear for the next election. We need to get them on the record for the campaign's to come, so they can't wiggle out of their choices like they tried to do by lying about protecting pre existing conditions after voting 2,000 times to repeal. And i like very much Mr. Krugman's take on how to go about health care. The mostly red states who opted out of medicaid will now pay the price to voting to not help people in medical trouble, as some of these states under Democratic control are opting in. A big victory, but you gotta get them on their votes to keep it going. It seems clear that healthier nation will be a happier, more equal, and as a result more productive.
3
I’m not too informed on our healthcare system as I am on other issues, but it is very fair for me to say that the debate over it is toxic. I will never know understand why the GOP despises the Affordable Care Act so much. Is it the expansion of Medicaid? Is it the provision that forbids insurers from forcing customers to pay more for protection of pre-existing conditions? I don’t know. Perhaps it isn’t Medicaid, as voters in states where the Republicans have robust holds on the legislature opted to approve expansions of Medicaid. That leaves the question; is it the pre-existing conditions? Political analysts have said that healthcare was likely a major contender in the GOP’s majority being voted out of the House. The horrid bill from last year that would have slit the ACA’s throat, the American Health Care Act, did have a provision that continued the ACA’s ban on insurers denying coverage for pre-existing conditions, but it had a program that allowed states to waive protections that told insurers they couldn’t charge higher rates on pre-existing conditions. Thankfully, the Senate trashed that wretched bill. Now, with a Democratic House and Republican Senate, efforts to kill the ACA after January may get through the Senate but would surely be trashed in the House. I will acknowledge that flaws exist in the ACA, but trying to wreck it and shove a bigoted replacement bill through Congress won’t benefit anyone. We need more bipartisanship in Congress. I think we’ll see some soon.
1
This article, interestingly, seems devoid of substance. However, healthcare is our number one issue and should be. Without a person's health, that person can't be at their best, may not be able to work, create, think, or help do other acts of good as much as they could if healthy.
Expanding Medicaid is not helpful for two reasons: It doesn't expand/guarantee access to care and it doesn't cover our illegal alien population, and we should not let 12 million people just die in the streets either.
1. Medicaid reimbursement needs to match Medicare reimbursement. Then a Medicaid patient would be more desirable for doctors/hospitals, or at least not be a "loss" as it occurs now due to our underfunded Medicaid system.
2. Medicare for all as an OPTION beginning at age 26 to age 64. This eliminates most in and out of network problems, as the provider list is now all doctors that take Medicare. You really CAN keep your doctor! This would be premium based with higher premiums for smokers, diabetics, and those categorized as "obese" by BMI. While these parameters will cause arguments, it already happens anyway and at least the more costly overall can get quality healthcare and NOT be denied, or have a higher deductible/coinsurance.
3. Force drug cost parity with a bucket price of average pricing from 6 or so developed nations. Like Belgium, Canada, England etc. Medicare doesn't need to " negotiate" anything. Just set the reimbursement. Savings fuels Medicaid fee schedule equity/cost.
2
Can I also have a pony?
7
Now that we have the biggest number of elected Democrats in the house since 1974 (39 so far, as opposed to what - 49? In 1974? Something like that) we need to look at 2020.
AND...we need to take the lesson of 2018, which IS, that this election was won by appealing to the electorate about a MASS TRACTION ECONOMIC DEMAND, which is HEALTHCARE.
This is the problem I have with the Dems and their identity-group-herding-cats program.
Its not that I object to identity politics per se - but the Dems take it too far. The thing that works is MASS TRACTION ECONOMIC APPEALS: HEALTHCARE; HIGHER WAGES; Expansion of Social Security; etc.
I am somewhat fearful that the Dems half FELL into this, without REALLY realizing what it is that made this election such a historic one in American history. I would add my admonition to rinse and repeat this mass traction economic appeal in 2020 - and THIS time, DON'T FORGET the one identity group that Hillary seems to have forgotten ON PURPOSE, and which cost her the election - MIDDLE AGE, WHITE BLUE COLLAR WHITE GUYS!
Can blue states band together and pool resources to create a broader-based public option? Call it BlueCare. Eventually it could become a nationwide single-payer program, once red states see its benefits.
2
The 1500$ in savings per individual in NJ is more than most of the have nots received from the Trump tax cut. That savings will repeat annually unlike the Trump tax cuts which will expire (except for the corporations of course). That also needs to be emphasized.
3
Is there something wrong with the affordable health care that the Democrats delivered in 2010 when they had the white house and the congressional majority? Oh Bill Clinton calls it the worst system in the world.
Health care for all without precondition is achievable if there is a hybrid public private health care. By that I mean 3 types of health care. A private insurance for whoever can afford it until the age of 65. A government managed health care for those below 65 who cannot afford private health care and of course Medicare for all those 65 and above. Those calling for Medicare for all can stop barking up the wrong tree. Many Americans don't know how complicated Medicare is and how limited funding is available and tinkering of Medicare would be a disaster for those currently on Medicare and those likely to get on Medicare in the next few years.
1
Health insurance should be available to all working adults. Able bodied unemployed adults should not be covered. By limiting the coverage to deserving adults and all children it will become viable.
1
Marika, what comes next? Oxygen and water only for those with jobs?
12
Democrats need to make a better effort in communicating the benefits of ACA while also addressing Republican intransigence to Americans, including their own fellow middle America Republicans, having affordable health care. Why is it always the Democratic Party that must expense political capital to do for the many while the Republicans expense none while in blind servitude to the few???
2
The shoal in the water to be avoided is a plan which allows republicans to say "aha, you want to drive private health care out of the market then impose your socialized medicine which failed in such and such a country".
to take an example of how such argument can be avoided, I'd say dems should say they have no problem with medicare advantage plans, always provided they offer "a t a m i n i m u m" the same benefits medicare provides.
If that condition remains as the clause paramount in medicare advantage plans, then more power to medicare advantage plans which may offer, just as an example, free gym membership, expanded dental, eyeglasses etc for some additional premium, or at no additional premium is certain providers are used.
The democrat competitive works when expertly regulated, the republican model doesn't work be it called corporate socialism or non-competitive unregulated monopoly.
1
Starts enrolling new-born babies in Medicare, basically under the same terms and condition of Medicare/Medicaid. After 5 years, the billions of dollars saved will permit the enrollment of all other Americans over an additional ten-year period. All health care can be paid for easily with a one-tenth of one percent cash flow financial transactions tax dedicated to health care. The tax would have no exemptions, no deduction, no exclusions, no returns, just immediate .1 of 1 percent taken out by the banks and sent to the government. Just like what credit card companies do, but .1 of 1% instead of 1.5 or 2%.
1
It will be a fitting irony if Democrats can preserve affordable health care for those who desperately need it by taking a page from the favorite book of the most conservative Republicans.
States’ Rights can mean freedom for the poor and the working poor, instead of being a Republican catch phrase for enslavement and exploitation.
You want to goose the sign-up and stop the insurance pools from being filled with only the sick? (1) Change the tax law and allow individuals to pay their insurance premiums before tax like all of you who get your insurance through your employer. It' s only fair. It would encourage a lot of small business employees to want to CHOOSE their own insurance. In 5 to 10 years, almost every small business would choose this model as opposed to managing a workplace health care plan. (2) Put ALL Federal Employees into this style of insurance where they buy their own insurance pre-tax from ACA exchanges(including the Senate and House members). Now its built in that a huge portion of Americans are in control of their own health care and it travels with them when they leave jobs and your pools are random instead of being filled with the sick. These small changes would pay big dividends.
1
1. Federal employees already are.
2. Small businesses can do that now, but are a) exempt if they have fewer than 25 employees, b) are provided with subsidies if they want them.
3. If you buy in the Marketplaces, you can choose now.
4. Sigh.
2
The United States is the only country in the industrialized world where citizens have the strong desire to be 65 years old just to qualify for Medicare and have finally some peace of mind in the chaotic and rapacious healthcaresystem , always on the verge to deny them rightful medical coverage .
Just copy the Canadian National Healthcare System .
No Canadian would switch to this Wall Street dominated fragmented and immoral healthcare abomination.
5
Up until the late 70s there was a term used that characterized Washington politics: "The loyal opposition". That term has disappeared with the rise of extremists in both parties. Maybe if the Dems could appeal to the Repubs in terms of "The loyal opposition" that congress could rework Obamacare to benefit all Americans. Just saying...
1
I was recently behind an elderly man in line waiting for a prescription. The pharmacist gave him a tiny jar of pills. The man, whose hands trembled severely, gave her 4 hundred dollar bills. I can only think to myself (having a $10 co-pay) that something is gravely wrong in this country. I don't know this man's financial nor health situation, but paying $400 for what he received is criminal.
5
Republicans suffer from two preexisting conditions which their president shares. Those are greed and heartlessness. Although these conditions are covered under the ACA, they are almost impossible to successfully treat.
6
First, we must get rid of Mitch McConnell, second, the GOP senate, and third rid the White House of Trump, all the Trumpites, with a heavy dose of fumigation.
Then the dems can propose and enact a universal health program, with a single payer, i.e., medicare. For all. Not just the rich and the right wing. Not just white, male, angry, left-behind Trumpneyland people.
6
I believe exposing hypocrisy is good thing anytime any day. Having the health care discussed, debated or defended forces the GOP to deal with it. Repeal is a policy by strict definition the replace part is policy, but the GOP has never offered their alternative.
In a fit of honesty the initial thinking was repeal Obamacare making it effective in two years or 2018. Two years believed to be adequate time for the GOP to offer their beautiful plan. Shot down by conservatives, repeal means repel, jerk it up the roots.
Like the disparaged issue health care, climate change represent another lever of discomfort for the GOP. Democrats are on the right side of both. The public has a substantial stake in both. Liven up the Congress with more than oversight, direct the debate to things that really matter.
1
Of course Trump voters say they want affordable health care, whether it be Medicare for all, or some similar program. But they will never, I repeat never, support anything that the Democrats propose.
And since Republican voters are now simply Trump voters, I'd say it's time for the Democratic leadership to cut this segment of the population loose. Give up trying to "reach out", to convince them with facts. They don't care. Any program the Democrats would manage to deliver on would help Trump voters anyway, and then of course they'd say that their Dear Leader, rather than Democrats, was responsible for this wondrous development.
Whether it's affordable health care, affordable higher education, or jobs and retraining programs, there is simply no purpose at all in the Democrats trying to reach out to Trump voters. The only way for Democrats to succeed is if they can squeak by in 2020 with a slim majority of their own voters, and once again control the House and the Senate, and have a Democratic President.
Until then, Democrats are simply wasting their time trying to convince Trump voters of anything. They are too invested in their hatred of brown people, their hatred of religious minorities, their hatred of the LGBTQ community -- in short, anybody who is not white, straight and Christian. This hatred is what motivates them -- not skyrocketing health care costs. The sooner the Democrats figure out they're wasting their time pandering to these bigots, the better.
8
From the NYT today ...
"One in three Americans can’t name a single branch of government, nearly three in four don’t know that the Constitution is the supreme law of the land and 10 percent of college graduates think Judge Judy is a member of the Supreme Court."
And you ask, "How Democrats can Deliver on Health Care"
Forget health care.. Let's concentrate on education.
9
Professor Krugman breezily endorses "actuarially sound government plans" but can only point to New Jersey's foray (fiscally dubious and heavily funded with federal debt), along with the idea of expanding Medicare (already fiscally broken and a moral hazard, as some commenters note here). Some of the most knowledgeable commenters here talk not about throwing more borrowed money at a system that lacks price transparency and hard choices instead of "Do everything imaginable!" Yes, the Republicans have been obstructionist, but the Democrats have been myopic about the lack of fiscal and personal discipline in the system. Professor Krugman is in a position to propose some fiscally sound compromises, but he seems to blow off any compromise as an impossibility. That leaves him with a feeble federalism papered over with more federal transfer payments. We need him to be a rational optimist, not a jaded political pessimist. Professor Krugman at his best is an economist. He might return to those roots and quit the political handicapping.
2
One major event that you forgot Paul is that more states are opting into the Medicaid expansion that was part of the ACA. (Even RED states!). Medicaid expansion is a huge part of the decrease in the number of uninsured Americans.
6
If everyone had the same medical insurance and access to all medical institutions, doctors and specialists then a dire shortage would result and those of us who have paid for quality care will be in a world of hurt! The quality and accessibility would be that of, say, places in the third world! Keep it as it is, and pay your way to good care as the President suggests is best for all...
2
@Moe, Maybe a couple years ago you could get away with these phony arguments but as of today many more Americans, even in the 'red states,' are educated as to the facts: the other advanced nations are very happy with their universal health care, the lifespans of people in those countries are longer than those in the US, when you include the insurance companies' costs those countries are have lower cost health care, Republicans really aren't interest in improving the ACA but just want to destroy it, etc.
8
@bill
You are missing the point.. there aren't enough doctors to treat everyone!
It's good to hear Prof. Krugman endorsing, e.g., Medicare buy-in for all, or some other government-supported health care programs.
It's a shame that he supported H. Clinton during the primaries, even in the face of her "Never happen" response to that or similar suggestions.
1
Why is it that "Obamacare" and Nancy Pelosi has been thoroughly demonized over the years, and Mitch McConnell has not? Nancy has been a godsend to the uninsured, while Mitch has probably caused untold suffering to them.... Republican messaging gets startling traction out there...Democratic very little.
If we are to move forward as a nation, we probably need to come to grips with the enablers of propaganda in our media. I'm starting to think that mainstream media content editors are, on average, surprisingly racist and indifferent to the poor, and echo compelling but harmful rhetoric--including demonizing messages--at their expense. Good ideas for good governance aren't judged to be "newworthy" and are regularly drowned out by warnings about various boogey-men.
Just why is that...America?
274
@Terrence
Q: "Why is it that "Obamacare" and Nancy Pelosi has been thoroughly demonized over the years, and Mitch McConnell has not? "
A. FOX News.
76
Terrance, I agree! Living with many family members and friends who are Fox News junkies, I can say unequivocally that much of the media is to blame. These individuals repeat verbatim the words that are being spewed forth on a daily basis and the message is basically such that “they are coming to take your guns away” or “healthcare costs will skyrocket “or “they’re coming to take away your jobs “! When they parrot the message, those who aren’t paying attention, could be easily convinced. Call me a pessimist, but until the media changes (which is highly unlikely), I don’t foresee a death of the bogeyman!
44
@Thucydides - I agree. One network screaming paranoid conspiracy rants while other networks "report" that there's a story some other network is upset about X is not the same as reporting facts. Our major networks report the fast, easy, and sensational. They refuse to look for the facts and report them. Facts take longer, are often "boring," and don't get good ratings.
Part of the problem is reporting that feeds the poorly trained palate of its audience.
37
The 1st order of business by Nancy Pelosi and the Democrats in the House should be to open up Medicare to citizens between the age of 55 and 65. It shouldn't be too hard. Those citizens who avail themselves of the program would still pay the Medicare tax as they do now plus a monthly premium per person covered.
I suspect that after a year or so people in other age groups would be pounding on the doors to be let in also. After a four to five year period of age group absorption everyone not adequately covered by their employer's insurance would be covered by Medicare. The Republican Party could then choose to either get on the train or get ready to become an obsolete political organization before 2030.
234
@JoeHolland
Agreed! Yes, please let us in! I am 61 years old and self-employed. I would love to move back to my home state (AK), but can't because the premiums are so high (small pool). This would do it for me. I also have a number of friends who never had kids and are in their mid- to late-50s. They want to retire and hand the job over to younger folks. But cannot do so without access to health insurance. We need to fix this.
137
@Alan
Actually, Alan, if you visit those countries and talk to their citizens, 98% of them are quite satisfied with their single-payer/universal healthcare.
It turns out that nowhere in the world are citizens clamoring for America's 'free-market' healthcare rip-off that sends people spiraling toward sticker shock, middling outcomes and bankruptcy.
Sure you can always find anecdotal evidence that some Canadians came to the USA for quick hip and knee replacements, but the reality is that most Canadians and Europeans are free to live their lives in human dignity without the uniquely American terror of getting sick or injured and going bankrupt....because the government regulates most of the greed and blood profits out of healthcare...sort of like Medicare....which it turns out works well for seniors and would fine for every other American.
America's healthcare economics are uniquely disgraceful, cruel and extortionist.
393
@JoeHolland....would Pelosi and other Dem powers do it? Only in America among modern nations, do citizens have to 'be pounding on doors to be let it' to a Medicare plan at younger ages.
Equal protection of the laws? What's that?
1st, the Dems have to plan it, sell it, and withstand GOP persecution as big govt socialists. They need election money.
This stuff about gradually lowering the Medicare age over years in the 21s century is sickening. What do we do in the meantime? There are millions of middle aged elderly whose jobs were sent to low wage countries, who need h/c, pensions, etc.
This isn't how democracy operates. Let's stop pretending.
26
The simplest solution - called the "public option" in the early stages of creating the ACA - was immediately and convincingly shot down very early in the process. There is a reason for that - the private insurance companies know very well that they cannot possibly compete with a Medicare-like program that doesn't require enormous expenditures for CEO pay and profits. So what makes us think the same thing won't happen at the state level if this great idea catches on?
The problem isn't in Congress - at least not directly. The problem is the influence of the profit centers on our lawmakers. Until and unless we find a way to curtail this influence, it won't matter much whether changes are attempted at the federal or the state levels - the corrupting effects of money in politics will continue to rule the day.
164
@TM: How many CEOs are needed to head up a fractal self-organizing system?
4
CEO pay is ridiculous, of course, but it’s not where the money is. And health insurance profits simply aren’t anything like what you think.
3
@TM
Sigh. You point out possibly the major economic and social flaw in our society that needs to be fixed - namely, allowing sky-high income levels - not only for insurance compary CEOs but everywhere. Let's not forget - in Eisenhower's administration the income tax at the too-high salary point was 91% - yes. And there was no shortage of CEOs, sports and other entertainment stars, etc. etc., paying it.
It solves two problems at once - obscene income inequality goes away, and BTW government gets some nuch-needed income.
20
Obamacare was based on Romneycare which has been in place in Massachusetts for over a decade.
Republican efforts to dismantle Obamacare damaged our state effort by imposing national stupidity on a good effort.
https://www.bostonmagazine.com/health/2017/03/13/aca-repeal-massachusetts/
It's complicated ...
3
The number one reason for high health costs is consumption. We are the only country who ramps up spending on fruitless efforts at the end of life. 45% of medicare dollars are spent in the final 6 months of people's lives. And that is not spent on comfort care. It is spent on ICU care, fruitless life-extending surgery and drugs. Life is not forever, and should not be treated that way. I despise operating on people who have no hope, causing pain, because families or patients say "try everything."
The first thing that needs to happen is America needs to take a long hard look at what it pays for before it determines how to pay for it, or how much to pay for it.
201
@Ny Surgeon: Belief in afterlife only seems to exacerbate fear of death in the US.
28
As a R. N. I agree with you 100%! I’ve worked in many a ICU and have seen firsthand what you yourself have witnessed. There needs to be more “preventative” care and education that happens at an early age.
28
@Ny Surgeon
Very true. I would guess that those clamoring for "universal coverage" and citing other countries' as example of its success never think about its underlying philosophy. Rationing care is one of its primary cost containment measures.
It is my belief that when Americans fantasize about "universal coverage" what they are imagining is getting all the care they want without writing a check or going bankrupt. Proponents rarely, if ever, acknowledge rationing.
In other words, when Americans think of "universal coverage" they mean plentiful American health care at universal prices.
14
The point has been raised, accurately, that a medical office practice can’t survive with just Medicaid/Medicare rates. I know this firsthand as a physician. But this isn’t true in Canada at all, in fact physician primary care providers do better than here. Why? Because the whole infrastructure of health care here is built around profiteering: exorbitant drug prices, unnecessary robotic surgery, unnecessary cardiac stents, for-profit hospitals generating obscene profits and executive bonuses. The examples are almost endless. Dartmouth researchers have shown that with smart health care, the best is often the cheapest.
If one starts with the premise that everybody gets covered medically as a right, the infrastructure described starts to melt away. A single payer won’t allow these abuses, and eventually overhead shrinks for practitioners. Like Disneyland, the wealthy can always pay more to be seen faster outside the system, as long as they pay their share of the primary system.
The top heavy inefficient and bloated medical/insurance/industrial complex we have now is doomed. ACA was as good an attempt at redress as you can get while leaving the current system intact. But it’s all duct tape till we change the assumptions on which the health care edifice is built.
500
@Phaedrus
The whole for profit pricing structure needs to be reformed, it must be done on the national level. Individual states will be unable to affect the pricing structure unless they are sufficient large part of the overall health care picture.
57
@Phaedrus
Agreed. Thanks for articulating it so well.
32
@Phaedrus - While you main points are correct, if a physician can't make a good living from seeing only Medicare patients, he is not running his practice very well.
You can find results with data for 2012 at http://healthaffairs.org/blog/2012/10/02/do-medicare-and-medicaid-payment-rates-really-threaten-physicians-with-bankruptcy/
I am sure today the figures would be even higher.
The author, a private practice orthopedic surgeon, looks at orthopedists and family doctors. He finds that an orthopedist who had only Medicare patients would have a take home income of $411,000. I could live on that.
A family doctor who had only Medicare patients would end up with $137,000, a lot less, but you know I could live on that, too (which is more than I ever earned) if I didn't serve Chateau Petrus on weekdays.
39
A state like NJ or CA can implement the types of programs that Krugman is advocating primarily because they have a population big enough to support a competitive insurance market. The problem with having 50 separate markets is that some states don’t have the population to support a competitive market. What we should be doing is setting up regional markets perhaps using the census regions as an overlay that allows states to work together to to establish competitive healthcare markets.
It would also be good if these markets included one or more non-profit entities. They don’t have to be government entities, just non-profit. Much of the EU had private insurance similar to the US - Germany and Switzerland for example, the difference is that these insurance providers are all non-profit and tightly regulated.
103
@Jeff
Not only Germans and Swiss, but most other advanced countries in the world, have mandatory universal health insurance by law.
Only those that have an income of more of about Euro 58,000 are allowed to chose private insurance.
An employer splits the health insurance costs with the employee, each at 7.3 percent of the net income, be they publicly insured or private.
Overall, while the US spends more than 17% of its GDP on health, Germany and other OECD counties spends 11% and less on healthcare.
No only do all countries with universal healthcare from pre-birth to grave spend much less per GDP than the US, their citizens are overall more healthy. They ave a longer life span than the US, less obesity, less mothers dying in child-birth, less infant death, less abortions, and the list goes on ad infinitum.
30
@Jeff
Or maybe Medicare for all?
Then the less populated parts of our country could get access to better facilities like the ones those of us in highly populated parts of the country enjoy.
It's kind of like the federal highway system. We all need good roads just as we all should be entitled to good health care.
When we get sick, the only thing we should worry about is getting well.
23
No, I don’t have problem with that. My problem is why Democrats didn’t win all the states. Is it because these states that are economically lagging often vote against their own interests or do they believe that if they can’t afford to buy their own health insurance, they can’t have it because that is the way god wanted to be, aka, karma? Democrats who won with a pledge not to support Pelosi should find a way to support her or else risk loosing Democratic vote on the next go.
5
@Kodali: Democrats do poorly where people believe their fate lies in the hands of God. Apparently we are believed to be an irritant to God who then takes it out on them.
1
It would be interesting to know to what extent our health costs are affected by undocumented immigrants. The government reimburses hospitals for their visits to the emergency rooms, the deliveries of their babies, and any long-term hospital care, but the amount the government pays does not cover the hospitals' full costs. Hospitals pass the amount the government does not pay onto their other patients. How much more are the rest of us paying to subsidize the undocumented?
3
@ann: It depends on how you treat cost savings from lower wages paid to undocumented workers. If the health care system were funded with a value-added tax, as many systems are, everybody would pay a similar fraction of their spending for it.
2
@Steve Bolger
Employers can get away with underpaying workers (citizens, legal residents, and the undocumented) because there are so many workers for the jobs that have not yet been out-sourced or taken over by automation. We have 1.4 million people, who are in what would be considered their prime working years, who have become the long-term unemployed. Many of them would be working if we did not have millions of undocumented workers flooding the market, and they would be earning higher wages than employers are currently having to pay.
The PEW Trust has been telling us for years that the number of undocumented migrants is between 11 and 12 million. Using new data, professors at the Yale School of Management say there could be over 29 million. In addition to the undocumented are those who have requested asylum and are waiting for their immigration hearings. Many states let the latter sign up for Medicaid (which reimburses hospitals at a low rate).
Americans are subsidizing a great many foreigners who are living here illegally or who are waiting to meet with an immigration judge through our federal, state, and local taxes, and through our insurance plans and medical bills.
1
@ann Yes, it would be interesting but irrelevant to the reforms we need. The poor, citizen or alien, get free medical care because they cannot pay for it and the rest of us will, in one way or another, through taxes, higher premiums and higher fees, or all three. The worst part of our system is that median-income working people shoulder too much of the burden and healthcare costs take too big of a bite out of their budgets.
2
is it really complicated? Expand Medicare to 55. those people pay a Health care insurance premium, similar to what you do with car insurance, it will hurt to pay the premium, but it will cover you for everything, just like your car is covered for any accident. The premium goes down for people who quit smoking, and come in under certain weights, which makes everybody get healthier.
As for a doctor shortage, the government subsidizes the education of qualified individuals, who promise to give 10 years of their career covering Medicare patients.
These are just some ideas, all of which are a lot better than one the Republicans are offering-which is nothing.
11
@artfuldodger
Just a reminder...my wife and I are over 65...we have Medicare and we pay a total of $270.00 per month IN PREMIUMS to Medicare. Medicare is not a free healthcare ride. And in addition, we pay a reasonable premium per month for supplemental insurance to cover what Medicare does not pay.
7
I cant speak for Nevada, but Florida, in most counties, has access to Medicare Advantage plans that do not require any supplemental coverage.
@artfuldodger Agree with all your ideas except the "punish the unhealthy" aspect. We already have enough hate to go around. You have to consider mental health as well as physical. Fat-shaming and smoker-shaming have psychological consequences. Besides, both eating disorders and tobacco addiction are conditions that need both medical and psychological treatment. And why would you single out smokers and overweight people but not heavy drinkers and illegal drug users? Very few Americans meet all the lifestyle standards for maximum health. Just stop judging.
1
Democrats need to focus on two things, at least here in Texas.
-First: Medicare for All doesn’t have to mean Single Payer. It could easily be a hybrid system where everyone has limited Medicare benefits, and people can buy private insurance to fill the gaps.
- Second; the health insurers hold their own future in their hands. If we wind up with Single Payer, it won’t be because of a handful of ultra-liberal Representatives from the East and West Coasts. It will be because hard working, middle class Americans are so fed up with the games, denied claims, opacity, poor customer service, and outright lies of private health insurance companies, that we honestly believe the government could do a better job.
Focusing on these two messages will put an end to the “socialism” fear mongering on the right while also providing a realistic path forward for reform. It sets Democrats up to win.
12
So, this is my family history, My grandfather, and two great uncles, (my grandmother's two brothers), who were all from the Bluffton, Pandora area of Ohio, went to the University of Chicago Rush Medical College, and became both doctors and surgeons back in the early years of the 1900s'. They ended up practicing medicine in two towns, Windom, and Mountain Lake, Minnesota, and helped each other with surgeries. From those three, we had another 10 together in the second, and third generation, most of whom attended the University of Minnesota Medical School, three married into the family who became doctors. It was the era before either any health insurance or government health insurance. The groups were all very competent, no malpractice against them, and they gave away a lot of free care. They weren't into medicine for the money, as they had a love of people from back several generations, most of which had a Swiss German background, and as persecuted Anabaptists. I learned everything that was important from not only living around them, but asking lots of questions. They would all agree that healthcare is a human right.
18
I went to my doc for a routine checkup earlier this week. The nice young woman who took my blood pressure was an RN with 6 years experience. I told her I was thinking of retiring and wanted to make sure I had nothing seriously wrong before I did so. She said that was a smart idea and told me how hard it was for her to afford the out-of-pocket medical costs for herself and her child.
When I mentioned to her that lots of other countries have universal health care, she was genuinely surprised to learn that there was such a thing. It was an eye-opener for me that there must be tens of millions of voters like her, who haven't a clue how comparatively costly, ineffective and counterproductive our healthcare system really is. Plus tens of millions more who have succumbed to years of "socialized medicine" scaremongering.
Between now and 2020, Dems and their allies should be disciplined and relentless (like the Reps) in their messaging
- exposing the worst of our current system (millions uninsured, obscene CEO salaries, admin costs double the global average, hundreds of dollars for drugs that cost pennies to produce, $1,000 per mile ambulance rides, etc)
- build acceptance for the idea that universal health care is not only affordable, but also best for jobs and economic growth, as well as being the civilized (and Christian!) way to go
22
States that do this would also be more attractive to employers
11
Two points:
1. Millions of Americans still lack decent dental care coverage. I have read 87 Million. Many states do not not include dental care coverage even with Medicaid expansion.
2. The Democratic Party and other organizations should promote Medicaid expansion referendums in states that still do not have it. Three states just adopted Medicaid expansion via referendum in the last election. These referendums were a resounding success. So if the Democratic Party is at the forefront of promoting these referendums, this could help them in 2020.
7
The biggest problem with our health insurance system is the complicated and unfair distribution of tax subsidies. Employer provided health insurance is 100% tax free, Medicaid is tax free and wholly subsidized, Medicare is tax free and partly subsidized for all participants, ACA is partly subsidized for some people, and everybody else pays through the nose.
9
My district went straight Democratic. Yes, we replaced a Republican in the House, and returned a Democrat to the Senate, but we also replaced Republicans with two Democrats in the State House and Senate, and replaced a Republican Governor with a Democrat.
Nobody wants to hear that is not enough, the Republicans in the Federal Senate can stop anything and everything. If all of those Democrats are that useless, then it would be time to look at something else.
2
I would like to see an economist analyze the cost to American business of providing commercial group health insurance to employees. This is the elephant in the room in the healthcare policy debate. Nobody seems to talk about it. Why not?
The data is out there. A simple Google search shows that the total cost of healthcare, including premiums and out-of-pocket payments for care for employees and dependents, is approaching $15,000 per employee with employers paying an average 70% of the cost ($10,500) and employees picking up the rest ($4500).
Health benefit costs are still rising annually at two times the rate of wage increases and three times general inflation. That means even when workers get a small raise or tax cut, they still fall behind.
Yet, whenever a single-payer or "Medicare for All" proposal is made, the first thing opponents scream is "Higher taxes!" without answering, "Higher than what?" Would taxes on employers and their employees be higher than what they are already paying private insurance companies? Would payroll taxes be a percentage of earned income, as Medicare taxes are now assessed, so that employees in the middle-to-low end of the wage scale pay much less than they do now? Would employers also pay less than now on that basis?
We will never get the "better, cheaper" system we need until we talk about the true costs of the system we now have.
13
@abigail49 Very good, Abigail. I'm a retired faculty from the University of California system. My wife and I are covered under the retirement health care, mostly my wife because I'm on Medicare, but have a supplemental PPO through the university system.
However, UC pays nearly $13,000 per year, and we pay (mostly my wife's cost) over $5700 per year. That's pushing $19,000 per year, and my cost to UC since I'm on Medicare is nearly nil. My Medicare costs me $1620 per year, plus any co-pays. So, my wife and I are paying well over $7000 per year, and my former employer and the taxpayers of California about $13000 per year. Between us that's over $20,000 per year not counting any extra that is paid for co-pays and services not covered.
So tell me, and the rest of rational America, how single payer would cost us and our employers more.
6
And the true costs of what you cheer for.
You’re paying that much because you’re out of state, you’re using a supp health plan that hits retirees much harder, and you’re not in a good HMO.
Paul. That is why Pelosi should be speaker. She has the talent to put together a monster bill that includes Health Care, Tax Reform (undo the give away to the top 1/10 of 1%), Voting Rights (undo the Jim Crow pushed by the R's), DACA (some other immigration reform?) & Infrastructure, the latter including not The Wall but an intelligent use of electronics along the border (which will be more effective and less costly than The Donald's concrete monstrosity, but he will still get bragging rights). Okay, maybe it's five bills. It will be fun to watch.
6
I am an occupational therapist and have a 43 year career in all of the health care settings. I am vastly familiar with all kinds of insurance plans and coverage. I will be 65 in three months and just now have re-read my annual social security income at 66 and the costs of Medicare. It has taken me hours on my laptop and cell phone to decide on plans. I never realized that my 2700.00 max social security income would be deducted by over 300.00. Unfortunately the shock only comes when you reach 64. How does the average person who has no savings, no annuities, no inheritance and don't own a home survive? Yet, we have paid congress exorbitant salaries and provide them with excellent insurance and a healthy pension.
12
Is there no way to bring back the individual mandate at the Federal level? The ACA needs fixing! But not destruction. Have friends at 62, with monthly premiums of over 1200...this is just plain WRONG. These people are just desperate for age 65 (Medicare) to happen...
10
Allow an option to buy into Medicare. The solution is right under our noses.
8
Ouropinion: The Democrats can contribute mightily to Health Care in the U.S.A. by sweeping the house and senate and presidency in 2020. If so, the massive reduction in everyones' cortisol level and other stress caused damaging hormones alone will improve the overall health of the population.
A comprehensive universal health plan, to include mental, dental, pre-natal, etc. care and rigorous cost control - preferrably a single payer plan if health insurance companies can not be reigned in, would be ideal.
To go along with all that good health endeavor, a rigorous but compassionate universal, free public education system, with accurate, fact based social studies/civics lessons plus free or extremely economical higher education venues would be ideal. An intelligent, critical thinking (based upon valid facts and figures), engaged citizenry could emerge.
9
Since only about one third of all jobs actually require college level skills and training, any program to have the taxpayer fully fund higher education must be founded on limiting that benefit to just one third of students. Those qualified to pursue STEM degrees should of course be covered, limited only by the corresponding number of positions needed. Those likely to become baristas and retail key holders, on the other hand, should be barred from consuming this finite public resource.
@From Where I Sit, dude are you seriously stating that only STEM degrees are worth the effort and investment? Sorry, some of the least educated people I know are engineers. I sure don't want them running banks, non-profits, public schools, art museums, etc.
@Drs. Mandrill, Koko, and Peos Balanitis with Srs. Lele, Mkoo, Wewe and Basha Kutomba
All good ideas, but I fear that the entrenched anti-education forces in the red states will prevent a lot of this. We are not Norway.
Democrats, whether at state or federal level, need to vigorously promote the idea that our governments are designed to serve We the People. Not the corporate interests.
If the republican model was so much better the U.S. would be a utopia and Kansas would be the most desired of destinations.
In the U.S. we have what should be their ideal: A vastly understaffed and underfunded Federal Government. Thanks, not to the party's brilliant plan, but to t rump's massive incompetence. Important positions in government are not staffed.
In Kansas we see a complete failure of "supply side" economics on display.
republicans have been calling our government "the Beast" and they have been trying to starve it for almost a half century.
We need to think of the government as a work horse that needs to be nurtured and trained to do what we want it to.
And we need to neuter the power of the koch bothers and their ilk.
8
@Bob Laughlin Absolutely. Reject the anti-government and anti-tax propaganda of the GOP. Government CAN do things right IF we demand it. We trust our government military bureaucracy to protect us from nuclear annihilation and conventional war invasions and willingly tax ourselves to give the military what it needs to do the job for us. The same Republicans who claim that government can't be trusted to operate a national health insurance program will never say a negative word about our military. They should be called on it.
1
No serious discussion about healthcare should leave out controlling prices of medical care. On average a US patient is paying 50% more for the same treatment as citizens of other advances nations. This is a huge drag on our economy, >however< it paid for. Opaque pricing, gouging sick patients who have cannot shop and compare, parasitic middlemen, and a shortage of doctors are some of the factors that need to be addressed.
The idea of the states paying is just an emergency band aid, not a solution.
10
@Craig H., great comment! My son's appendectomy 4 years ago cost $32,000. No overnight stay, no complications, a very healthy patient. Our share was 10%. We could afford the $3200, but for many people this could have been at the expense of food, tuition, car repairs, etc. In Germany I believe the price tag was less than $1000.
3
If we want every citizen to have universal medical care access, we need to Nationalize it.
7
The words trump and lie are interchangeable. The words are synonymous and can be used as a transitive verb.
"The little girl was in tears because she was caught trumping a candy bar."
"He trumped on his taxes, now he's going to jail"
Just a joyful thought game to play while waiting in line paying for Chinesium that costs more now because of tariffs.
(BTW tariffs are taxes on consumers.)
6
1. This is a good article, offering sensible choices.
2. No, every other country does not offer single-payer. They offer universal access, in a number of different ways.
3. “Single-payer,” means that one entity, usually the national government, collects all the premiums and pays all the providers. “Universal,” means that practically everybody is covered.
4. A lot of the folks yelling for single-payer need to figure out that a) their taxes will zoom climb, b) they will have to accept rationings, c) they will still pay deductibles and co-insurances, unless they buy supp plans. Because St. Bernie’s estimates don’t cover what he’s now demanding.
5. We will not get single-payer. We could get the 55-64 bracket set to pay into Medicare early (they’re the most expensive people to cover), fix a lot of the pharmacy problems, and require the expansion of Medicaid. Then, work on a public option.
6. Stop already with the quaint notion that insurer provider profits are 20-40%. And look at the Medicare/SSI figures up through 2040.
7. Gladwell was right: you have to choose between basic coverage (that’s rationed) for all, or extravagant and total coverage for a few. Look at the numbers for costs deriving from poor health, diet, flabbiness, blood pressure, stress and so on. That, with drugs we often do not need and fancy provedures, is where the loot is.
8. I continue to be distressed when lefties don’t know any of the numbers, and won’t look.
9. This is a very good column.
Vote.
3
@Robert "Stop already with the quaint notion that insurer provider profits are 20-40%. And look at the Medicare/SSI figures up through 2040."
Stop making dubious claims without providing credible links to back them up.
PS: "Rush or Fox said so" is NOT a credible link.
1
When will Americans realize that people who claim that government is inherently incompetent run for public offices to prove it?
9
Amplifying @FunkyIrishman.
Therein lies the rub:
"Unfortunately, the short answer is that conservatives all want to insert profit between you and your doctor. In fact, they want to insert profit between you and everything. - education, health care, military, government - anything.
It is their faulty modus operandi."
We will all be better off when we realize we can live in a fundamentally capitalist society and not need to make profit on absolutely everything. We already have some "socialized" aspects of our society. Think anything with the word public or municipal. Public education, public libraries, public parks, police forces, and of course social security and medicare.
We should be expanding medicare. Making guys in suits rich from being the middlemen in health care delivery is simply nuts. There is plenty of money in the healthcare system, let it go to actually delivering healthcare.
3
I agree totally with your notion of the states being able to do the heavy lifting on healthcare, but what about states like mine, Tennessee, who continue to outright refuse to do anything??
1
@Sharon I never understand Tennessee logic; Vote for Republicans that are bound and determined to take care of the rich at the expense of the 99% then complain the state government won't provide medical insurance. Obviously there is a solution, Vote out the Republicans.
2
Krugman's approach to our deficient health care system is to create "better" policies so that more people can purchase a flawed product, private insurance. Doesn't he realize that the goal of insurance companies is not to provide health care, but to make money that largely happens by collecting premiums and government subsidies; and providing as little health coverage as possible?
4
The law of unintended consequences. The Dems start to get things done on the state level. The grass roots strategy can pay off big time for the Dems. If they take over the state governments, it is only a matter of time before they control the Federal government again.
3
Actually they can't. Now of course states can do different things some of which will work for their citizens. As they have success some other states will follow. They won't work in every state, and if you think anybody should need more advertising for the ACA they must be mentally defective.
1
@vulcanalex The Republicans have never been in favor of any government sponsored health insurance. The ACA with all its defects was given birth by the conservative Heritage Foundation. Come up with a decent alternative and I will be happy to scrap the ACA. As if.
2
One might say that anybody who needs further evidence of Trump’s grotesque behavior and worse actions to stop cheerleading for him is mentally defective, actually. It seems to be the opposite of hallucination: you just don’t see what’s there.
We have health insurance in France since 1949 for everybody :teeth, hair, nails, etc... even for people not working.
And in most European advanced countries, except great Britain.
The same antibiotic made by Bayer cost 1000 $ ( 1 pill ) in the USA and a friend doctor in France provided it from a hospital for 40 euros = 50 $ .
Who takes the 950 $ ???
The problem in the USA is always the same , for everything : greed. And disrespect for human beings.
17
@JPH Or a diverse and much different population than any other country. France is a great country, but quite different than any state not only a large country.
1
@vulcanalex
When France hands control over its health care to the large bureaucratic EU, then we can have this discussion.
2
@JPH
That $ 950 goes to keep white collar workers in the middleman insurance industry and out of the marketplace where their skills are badly needed.
The average cost for fixing a broken leg is 7500. A three day hospital stay can cost 30,000. People without coverage can get into deep debt or even into bankruptcy:
https://www.healthcare.gov/why-coverage-is-important/protection-from-high-medical-costs/
But the median american household has only 11,000 in savings, and 30 percent have less than a 1000 in savings:
https://www.cnbc.com/2018/09/27/heres-how-much-money-americans-have-in-savings-at-every-income-level.html
So hospitalization poses a huge risk to the average american's life and finances-both.
Those over 60 face the greatest health and financial risks.
7
Remember too how GOP tax policy reinforces their sabotage of the ACA. NJ may decide to raise taxes slightly to help subsidize the cost of the mandated coverage for some. But the GOP effectively denied NJ taxpayers the ability to deduct NJ taxes on federal income tax returns. So the GOP makes it much more expensive for NJ taxpayers to thwart the GOP assault on the ACA.
And you can be sure that the GOP ads in the next election cycle will thunder against "out-of-control" NJ Democrat tax increases while ignoring that NJ's "undoing Trumpian sabotage seems to have saved the average buyer around $1,500 a year."
8
According to the Kaiser Foundation charts, the Medicaid Program is a 61% Federal, and 39% State partnership. The costs of this program as of September 2018 amounted to close to $600,000,000, according to the average annual cost increases. The problem with healthcare in this country, is that more, and more people in the 8 separate government programs( 1. Medicaid, 2. Medicare 3. Veterans 4. Current and former military 5. Current and former government employees 6. Native Americans 7, Federal Prisons 8. ACA). are basically getting free healthcare, and that is not good, in that the costs for a very unhealthy population, 60% overweight, and obese, drug addicted(15% of Americans are alcoholics, 1 in 3 Americans use or abuse pain killers(legal and illegal) which makes for ever increasing costs to both the state, and federal government really cost prohibitive. Politicians make the laws, but except for a handful, they aren't doctors, or in the field of medicine, so they should be the last ones who decide where we go from here. Let's see America is basically $22 trillion in debt, most larger states, and those that have large populations in their state receiving free healthcare, are having to borrow lots of money, as states must balance their budgets, unlike the federal government. In this country we don't have honest conversations about one's own state of health, the costs associated with it, etc., because we are basically infants, and have been for decades.
6
@MaryKayKlassen
Noticeably absent in all the Obamacare sales pitches was the mention of the consumer's responsibility and/or role in health care costs. Never.
Obama did say that people wouldn't mind paying more because they would be getting so much more. Wrong. Then came the big change from "access" to "enrolled" as a success measure, conveniently avoiding a discussion of how sky-high costs were actually deterring people from "accessing" (using) their health insurance.
4
@MaryKayKlassen Sure we all know the challenges. Now what are some of your solutions? The Republican Party has never been interested in comprehensive health insurance and basically swatted it away for decades until the ACA came along - ironically a conservative Heritage Foundation concept in the first place. They have spent the last eight years frantically trying to destroy the ACA. Where is their alternative?
3
@Chuck Burton The alternative is to focus on actual health care and being healthy rather than insurance. The ACA is a massive disaster for a small minority of citizens. There is not possible solution for our diverse population and culture to make health care cheap or affordable.
2
Why not, for example, introduce state-level public options — actuarially sound government plans — as alternatives to private insurance?
Because, depending on the state, actuarially sound governmental plans are going to be tough. States cannot run deficits like the federal government can. How will Illinois do this? Their bonds are junk as it is. I hope Krugman is right, and there will be a slow movement on the part of states that compensates for the lack of national health insurance. But I am not sanguine.
2
@Clovis
OK, Illinois was perhaps not a great example, because they did expand Medicaid. But the problems with State level expansion still exists.
2
@Clovis How they could do it is to just tax their citizens, after all that is how other countries do it. That will get many to move from those that tax so much.
@Clovis
The NYT reported that some states could not afford the costs that Obamacare would eventually transfer to states.
Heartening!
Why wouldn’t one want healthcare for all?
“The King will reply, 'Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.”
6
@Henry H P English You mean health insurance for all, and the reason is that it costs a lot and discourages being healthy. If you and others want to provide it, make a charity, fund it with your money and be happy.
1
@vulcanalex -- "discourages being healthy"? I don't think so. Everybody is required to have auto insurance, but does that encourage anyone to play in the street or on the freeway and risk injury? Or, I don't care if I get heart disease because after I have a heart attack or stroke, my doctor will fix me up as good as new.
4
Exactly right; democrats are showing in New Jersey what ought to occur, if people's interests are placed above self-serving politicians. And Health care Insurance is a basic feature we all can feel comfortable with...except the Trumpian republicans, trying to deny others what they take for granted for themselves. If the individual mandate is re-instituted, health care costs would come down, as intended. Obamacare is a thorn in racist Trump's side alright, as he wants to erase 'anything Obama', and elevate his stupid ego to a higher level of incompetency. For now, short of a universal single-payer universal healthcare insurance, the A.C.A. must do. All other advanced, and illustrated, economies, are scratching their heads at the U.S. pettiness in neglecting the health of it's own people. Let's prove them wrong by overruling republican hypocrisy and shortsightedness.
7
In Oregon we see uninsured people from Idaho who get seriously sick, then move across the border and immediately sign up for the Oregon Health Plan.
6
@Nick Benton
All the more reason for a Federal plan
After being pushed out of a good-income corporate job at 60 years of age, and using COBRA for the allowed 18-months, we faced a Hobbesian choice of 1) going without HC insurance; 2) paying retail BCBS coverage at $40K per year with a $6K deductible through the ACA; or 3) smartly playing the ACA system rules by keeping our "Qualifying Income" below the 2X Federal poverty limit of $32K by using other financial resources beyond the saved 401-K / IRA accounts.
We chose that latter approach since it is saving us $40K per year in HC insurance costs while we wait to reach Medicare age of 65. I expect we're among the few who invested the time & energy to research and understand these rules; and the even fewer who have the resources to play the ACA Income game effectively.
Why should others in similar situations be forced to go without HC or pay exorbitant rates? Implementing a Medicare buy-in option would be a lifesaver to many middle-income families.
22
@GTM Great points, but you are talking about health insurance, not care. And a Medicare buy in would be more than the ACA, it pays way more not to mention it would negatively impact all providers as more of their income comes at lower prices. That might mean some refuse to take Medicare at all.
1
@GTM
A buy in option sounds like a very good idea.
I experienced much the same excruciating anxiety of losing my job and paying the exorbitant but life saving COBRA costs. We savaged our retirement savings until I reached the medicare age of 65yo.
This country robs the federal treasury to give corporations and the wealthy 1.5 trillion in loot. When will Fox news viewers realise they've been had?
7
By removing the possibility of thwarting the Affordable Care Act, the democrats are making America healthy again. Continuing to push, especially in those states that are now majority democratic, will illustrate the benefits of the ACA under democratic control. This was the case for Massachusetts who's original medical coverage plan was the blue print for the ACA.
Beyond healthcare, I believe having a clearly understood and achievable sustainable energy and infrastructure retrenchment plan which creates real and meaningful jobs for the economy of the future would be a very welcome message.
So having two to three clear and achievable initiatives would go much further than trying to offer too many solutions for various consultancies across the land - which often seems to be the case in our elections.
7
@ZigZag
Yes, I am glad you mentioned Massachusetts. Under Romneycare we lowered the percentage of uninsured to very close to zero. And in my particular case, I got better coverage at less cost.
3
We need to show the dollar numbers. This is the big fear of those opposed. It can be complicated so the numbers need to be explained in a simple clear fashion and repeated. If the opponents can lose the its too expensive argument thats a BIG step.
Example. Family of 4 pays about $9,000and deductions added each year. It f they had their payroll tax doubled (assuming a $60,000 a year salary) they would still be many dollars ahead and no deductables.
2
Sigh. You would have to devote their entire payroll tax to this—schools much? How about, oh, the military?—and given deductions, it still wouldn’t cover the nine grand.
1
@RichardHead The problem is when the actual numbers are told, it is way too expensive. And many families won't meet that deductible in any year.
@vulcanalex and Robert:
When in doubt, just figure out a way to not understand what the original poster is saying.
The Professor is diagnosing the dangerous disease of healthcare by looking only at the symptoms. This incorrect analysis and his therapeutic prescription miss the underlying cause.
Our Healthcare does not work; it's ranked about 40th in the industrialized world. US Healthcare is ranked below Costa Rica, yet costs twice as much as top-ranked France.
Furthermore, studies by Harvard Safra's Institute show that pharmaceuticals are ineffective 90% of the time - but they all have side effects. People usually feel better when they get off their raft pharmaceuticals, not worse.
(In 2013, patients between 50 to 64 years had an average of 19.2 prescriptions per person.)
The problem is not how much we pay for health care, it's how to make it effective. Because it doesn't work - so why would you want to pay even $1 per month for something that doesn't work?
Acute care (surgery) represents 25% of healthcare costs, and that works very well. It's the other 75%, chronic care, that is responsible for our abysmal global ranking.
Our healthcare industry is killing us, and that's the real problem - not how much it charges to kill us.
7
@Fourteen
So rather than attempt to get our people health care insurance you are saying...no, the entire "healthcare industry" is killing us and Big Pharma, hospitals, medical professionals, the whole deal needs to be revamped? That sounds like "whataboutism." You were suspect when you started with "The Professor."
1
@Jeff A.
It's not at all "whataboutism."
"Whataboutism" is a form of logical fallacy, false equivalence, which first became popular in Russia. It's a fallacy of inconsistency between two items on the same conceptual level.
But I am differentiating between the cost of healthcare and and the quality or effectiveness of Healthcare.
Healthcare itself is up-level from its cost. There is no equivalence and they cannot be compared.
What I wrote about Healthcare is perfectly reasonable. So reasonable, to my mind, that every commenter, and also the professor should immediately agree.
To restate concisely, one should always rethink before you re-engineer.
First make Healthcare effective, then fix the cost structure.
@Fourteen
Where did you get your 19.2 prescription number? I cannot imagine people managing that many drugs on a daily basis. Is it perhaps lifetime prescription count?
My mother is 95, and has a pacemaker. She sees her doctors regularly and currently has only three prescriptions.
1
The Canadian health care system is operated at the provincial level. Funding and standards are coordinated at the federal level, although the Quebec system operates independently.
There is also private insurance, which most people obtain through their employer. Services like psychotherapy and physical therapy are covered by insurance up to a certain point, but can also be purchased privately.
Ontario and Quebec, the largest provinces, are comparable in population to New Jersey. The smallest Canadian province is comparable in population to North Dakota.
There is absolutely no need for the U.S. public healthcare system to be operated at the federal level.
There is certainly a federal role, just as there is in Canada and other countries. Size has practical advantages in regulating drug prices and purchasing equipment. A large public bureaucracy can, with with voter attention, be made more transparent than a private medical bureaucracy, where the customer has no way to fight back against abuse. Big Pharma has to be held in check by Big Regulator - anything else is wishful thinking.
However, a large “Medicare for all” bureaucracy at the federal level is not at all necessary, and the New Jersey model may end up being the example that other states follow.
7
@Global Charm: Health care delivery is a local and regional process. The federal level needs to set the rules by which the local and regional elements self-organize.
9
@Global Charm ..Canada is cited by many as what a Medicare-for-all system would be like if that version of single payer was adopted in America. Canada bans private insurance for basic hospital and medical care, but does allow private insurance for services not covered by the public plan such as optometry, dentistry and outpatient prescription drugs. The big difference between a likely American version of Canada's system and what Canada has now is that Canada spends much less on healthcare as a percentage of GDP than America. Canada does this with rationing, primarily long waits for certain procedures. Rationing of any type could be avoided in an American system, if the USA was willing to spend much more as a percentage of GDP than Canada does now. …"
https://seekingalpha.com/article/4223364
1
All I ever read in articles about ACA are the subsidies that most subscribers get and how little they pay, very little is written about people like me who foot the entire premium. I earn too much as a freelance computer programmer to qualify for a subsidy for my wife and myself, and as a result pay over $2,100 for a Bronze policy which carries a $15,000 deductible. When I mention this to anybody willing to listen I tell them it's the worlds most expensive catastrophic health policy.
I was a huge supporter of ACA when it was being debated and eventually passed in 2010, but not any longer. I now think it's the worst piece of legislation to come out of Washington in the last 50 years.
Interestingly, last week I was invited to a holiday party and was speaking to a German fellow who was a friend of the host. We got on the subject of healthcare and he simply could not comprehend the concept of why working for one company over another dictates whether an American would be entitled to receiving care. No matter how I tried to explain it to him, he simply could not understand. In the end he said that in Germany healthcare is never discussed because it's "just there".
16
@Marc Jordan. I am in the same boat although my husband and I are retired; I am hopeful that Congress will make a strong push to fix the ACA to address the folks in our category. The ACA should still be supported, but it has to be improved upon.
7
@Marc Jordan
Plenty of people in our boat were very vocal about their dissatisfaction, but only the republicans were listening. Partisans believe that the GOP's only concern is to rob everyone of their health insurance when, in fact, it's the GOP that is trying to address the untenable situation for the unsubsidized who are covered but cannot afford to access their care.
1
Quite honestly, I’m struggling to recall what meaningful legislation the GOP offered to fix the ACA. Their focus was to repeal and/or water it down to such an extent that it increased my costs.
8
Obamacare was the biggest success and the greatest failure of the Obama presidency.
He walked into a Republican trap trying to extend health insurance to more citizens. The result, it can be argued, essentially shutdown his presidency or at least neutered it legislatively for six years after the Republicans got control of the House and thus had the ability to deny Obama almost anything.
Was it worth it to lose control of the Congress, which was followed by massive gains by Republicans in governorships and control of state legislatures? In human terms, helping millions of people who might otherwise die, yes. In political terms it must be said that the answer is no. The political impacts the personal reality: we wouldn't likely have Trump in the White House now if Republicans hadn't been given the Obamacare sledgehammer to use on the Democrats.
Long ago, the much hated Nixon (by Democrats, liberals and moderates) proposed a national health care plan. The AFL-CIO, then the most powerful union force in America, opposed to because they and others wanted such a plan to be passed by Democrats. If it had gone through back in the late 1960s and early '70s, we wouldn't be having these destructive battles now. The world would be a different place.
Some good has come from all of this, however. There is now a general public recognition that health care is basic to a decent life and should be part of the basic plan for a respectful, civil society. Progress, hard won.
19
Medicare for all, that should be the Democrat's message and they will win. With over 70% of the American public, and 53% of Republicans, wanting this form of healthcare system that is available and functioning well in every industrialized, CAPITALISTIC economies around the world and even next door in Canada, they will have a winning message. The only obstacle from them doing this will be their corporate donors in the insurance industry calling in their bribes.
17
Please stop repeating this whopper about every other country having single-payer. They do not.
1
@Robert
He did not say every other country. He said industrialised countries, and that's not a whopper.
Yeah, it is. Canada does. With omissions you have to buy separate,y. England, France, Germany don’t. Italy don’t. Scandinavian countries, mixed bag. Australia, kinda sorta. Japan? Not really.
Look it up, okay? They do a better job with less loot, but rhey also have a healthier pop.
Yes, Mr. Krugman, I do have a problem with your citing New Jersey as an example of how the Democrats can deliver on healthcare especially when you write that rates for 2019 are going down by 9.3 per cent for 2019 there without mentioning that they went up in 2018 when insurance companies feared the loss of the mandate.
I have an even bigger problem when you look across the Hudson for effective healthcare policies and ignore the fact that, with 9 new Democrats in the State Senate, your home state has a chance of enacting improved Medicare for all under the New York Health Act and when you cite the public option as “actuarially sound” without saying that the centrist Rand Corporation has found that the New York Health Act, paid for by a progressive payroll tax, will save all but the richest 10% of New Yorkers over what they are paying now for a plan that is comprehensive, universal and affordable.
Private health insurance is killing Americans with huge co-pays, premiums and deductibles not to mention the constant delays of prior authorization. Affordable care is proving unaffordable for so many American families. New Jersey’s solutions are band-aids when we need to treat the cancer of healthcare costs with an overhaul. That’s what New York Health does.
12
It's not just that the nominees of the Democratic Party had no concrete platform in 2018, but that their Presidential nominee in 2016 didn't have one either! As was pointed out by President Trump and Senator Sanders and duly reported in the press. (Of course, Donald Trump wasn't President at the time. Hard to remember now, I know.)
2
Small businesses did not fare as well this year in New Jersey. I own a business with fewer than 50 employees. Our HSA plan was dropped by our insurer, Aetna, supposedly because of losses in our market. The closest alternative HSA had much higher co-pays (50%) and huge deductibles. Collective groups have not formed because there are large start-up costs. The State needs to do more to help small businesses.
9
@Richard Porwancher
Under Obamacare mom-and-pop small businesses could no longer be considered "small businesses" so we were shunted into the individual market, wherein we were soon dropped.
It's a small change that was disastrous for many small businesses like mine. Of course, I could divorce and regain my Obamacare small business designation. Go figure.
3
Yeah, that’s a lie. Obamacare exempts businesses with fewer than 25 employees from offering health bennies, and provides tax breaks and credits to those that do.
One major problem with Medicare for all is that it is still an “insurance” policy. As such, there is little disincentive to the overuse of medical care.
The ACA creates a partial fix to that problem with its significant deductibles. The dems, I suspect inadvertently, created a republican solution to health care financing by introducing personal responsibility to the payment paradigm.
1
@Tom Carlstrom the ACA is a republican plan, it was directly designed after the plan enacted in MA under Mitt Romney's governorship.
This whole concept of personal responsibility driving medical cost up or down based on how much people are charged in premiums doesn't hold up to reality. The rise in medical cost has nothing to do with overuse, and everything to do with captive markets, lax or no regulations, and a focus on profit making rather than preventative health care. Getting more people on insurance should lower premiums for all, that is a basic market principle, but letting people sign up for a public option and letting medicare negotiate bulk prices (which it is prevented to do by law) would do the most to create a more competitive marketplace for medical services.
14
@Tom Carlstrom So how are Blue Cross, Aetna, Humana, and other major health plans NOT insurance policies?
And as any subscriber is aware, Medicare already incorporates safeguards against the “overuse of medical care.”
Key plan differences lie in the percentage of premium dollars paid out in claims as well as corporate profit distributions; Medicare has no shareholders to appease. Medicare-for-all would also help reduce adverse selection—insuring a disproportionate number of old/sick people —which drives up claims costs.
Currently, high premiums, co-pays, pre-existing conditions and other limitations are used by private plans to cull out many of those potential losses.
Finally, Dems created a ‘Republican health plan’ because Obama realized that was the only way to accomplish anything at all. And for all its warts and wrinkles, ACA did provide health care coverage to 50 million Americans.
In the end, we have to decide if health care is a right or a free-market commodity like beer and burgers. In a commonwealth society like ours, that shouldn’t be a very tough choice.
9
@M
It's a fallacy that Obamacare was a republican plan. No republican plan ever mandated benefits like Obamacare did. That is a big factor in its cost.
Furthermore, after Romney left as governor, his predecessor started adding costly changes to Romneycare. It's no longer Romney's plan either.
1
Another example of Paul’s suggestion: I seem to recall that the Obama plan is modeled after a state plan introduced by Romney as governor. Who, of course, back-pedaled away from it as candidate for President to gain GOP support.
17
I always hear Democrats need to have an agenda.
I never hear Republicans need to have an agenda.
From what I can tell the Republican agenda is fear of immigrants and fear Obama is coming to take their guns.
That and Nancy Pelolsi wants to make the US a socialist country like Venezuela.
(I notice they never talk about Denmark or Germany, etc.)
Add to that, anti-abortion at the same time not giving women birth control.
And then what Republicans in Congress do is cut taxes for the rich.
Likewise, liberals are always encouraged to talk with Trump voters.
I never hear people tell the Trump voters they should talk with liberals.
I have been talking with them since before we had Trump, going back to when Reagan gave us dog-whistle politics of "welfare queens" and States' Rights.
Back to when Newt Gingrich and Rush Limbaugh began the divided politics we have now.
I have neighbors who still think the Clintons had Vince Foster murdered.
And it is not coincidence that our political divide is greater than ever at the same time our economic divide is greater than ever.
The top 0.1% has as much wealth today as they did in the Gilded Age.
At the same time, Ryan and McConnell are talking cuts to Social Security and Medicare. Again.
The billionaire class is laughing all the way to the bank. Literally.
69
@Independent
The Republicans have no message and need no message because they have something better - they have turnout.
The Democrats, on the other hand, have lots of policy prescriptions and a brochure of boring messages, which puts people to sleep and steps on turnout.
The lesson is that rather than go on about boring Healthcare, one should should motivate with fear and anger as in, “the Republicans will take away your Healthcare!”
If it rains people will not show up to vote for something, but they will get up early and stand in the snow to vote against something.
As noted here and in adjacent columns in support of Pelosi, in smirking contempt of Bernie Sanders, NYT and lead columnists remain firmly Corporate Dems - i.e GOP Lite - protective as ever of major investor portfolios against any rabble claims towards equity or equality.
Krugman offers little to no objection to ACA which still leaves medical-industry titans more or less fully in control of options offered to all Americans.
Have you visited Canada recently, Dr. Krugman?
10
@vishmael Might ask you if you have ever visited the U.S. Are you familiar with our political system? Maybe if progressives had turned out in '10 our situation would be much improved. The fact is that the ACA has established patient and insured rights, expanded the only single payer system that serves average age low wage workers, has provided Ca and NJ avenues to expand coverage and control costs, and oh yeah, it just BARELY squeaked through Congress.
22
@vishmael
Well, the best way to put Republicans in sole charge is to put out propaganda encouraging progressives to reject all other Democrats.
3
True dat, John. And you would have thought that Wisconsin lefties would have better stuff to do than harangue their own side.
1
Due to the money involved and the life and death decisions that accompany any policy this is a very controversial topic, but it does not have to be.
Take the emotion out of this equation as much as possible and one can see that there are many existing examples of a shared system like universal coverage out there
-Tax payer dollars used for our roads, bridges and infrastructure
- auto insurance ( can’t drive without it)
- home owners insurance ( can’t get a mortgage without it)
There are many examples ( nations ) throughout the world that deliver healthcare with better outcomes for less money.
They commit money to pool resources drive cost down and increase availability.
Saving everyone money ( those in the plans and even many outside of universal coverage) and save lives in the form of long term, consistent, preventive care.
If looked at without political bias, it is way more than doable
The healthcare “fight” reminds me of a famous saying (paraphrasing)
It is amazing how much you can accomplish when you do not care who gets the credit !
9
Fine, improve and save ACA, but do it WHILE the Dem majority in the House also pushes for discussion on Medicare for All. The insurance companies have to go, and more than 50 percent of Republicans agree that we should have Medicare for All. However, will Pelosi allow this discussion? Given that she is now pushing for a rule that would require a three-fifths majority vote to pass an income tax increase on the lowest 80 percent of the income bracket, I would venture the answer is NO! Clearly, the increase in taxes for Medicare across-the-board would be a substantial savings each year for American families who currently have to fork over outrageous sums to their insurance companies. Pelosi's maneuver here does not bode well for what is now a majority opinion of 70 percent of Americans:
https://www.nakedcapitalism.com/2018/11/staggeringly-bad-idea-pelosi-pushes-tax-rule-kneecap-progressive-agenda.html
3
Clearly the increase in taxes would not, actually. Please learn actual numbers.
1
@WRosenthal
While I agree that insurance companies add no value to our physical or mental health as a nation, they won’t go away any time soon. Until they do, could we require that they be not-for-profit? This might “thin the heard”.
1
@Robert Clearly, about 35+ other countries have successfully used taxes to pay for healthcare for all. In doing so, they provide better medical outcomes for more people than our privatized system does. If they can do it, we can do it. Here are some actual numbers: https://splinternews.com/medicare-for-all-will-save-trillions-conservative-wonk-1827975072
1
Let's get real here folks. The real question is whether we can afford to have a national health care system which covers everyone. The answer is, of course we can. The real hold up is whether we have the will to implement it and whether we can break the lock the insurance lobby has on the national government. It's probably more intense than the NRA's hold.
There is no question that Republicans are the culprits here and they have managed to further fracture was a fractured plan (ACA). It was conjoined in the same vein as the Clinton fiasco of the 90's, when he attempted to placate the insurance industry with a hybrid national plan, all in the name of "free market enterprise."
Health insurance doesn't work in that arena, you're not selling Buicks; you're selling something that everyone needs to have in order to survive in a relatively happy way.
It's nice what New Jersey did and maybe it works in other places, but we need to face the reality that every other industrialized country in the world has faced; national health care is a must for the health of the country. The sooner we do it (Medicare for all), the better off we'll be. And, as an added advantage, all the industry costs for providing health care will go away, so they can use the money to buy back their stocks as they've done with the tax cut that our idiot president gave them, which, incidentally, would have gone a long way toward paying for the health care of a lot of indigent people, . Happy Thanksgiving!
10
@Joseph Tierno Switzerland is an example of a country that has Universal Healthcare NOT based on a government provided healthcare system. It is actually LESS governmentally financed than our own system is. It is similar to Obamacare in that every person must purchase health insurance, the government subsidizes this purchase for those with less income and the insurance companies cannot cherry pick. What may be different is that the insurance companies must be strictly not for profit. But even here in the past, health insurance was not for profit.
Even Canada's system is 30% funded by private sources. And in Sweden, about one in ten get healthcare from their jobs.
4
Superb column!
5
I retired early from a good job in banking. I am now on the Omnia plan in NJ. I have every doctor the same as when I was on my employer plan. The only difference is my employer doesn’t pay 75% of the cost. But why did my bank do that when I worked? - it makes no senses. Employers should pay us a salary and we should buy our health insurance. My employer doesn’t choose my car insurance or my home insurance so why do they control my health insurance? It’s because of wage controls 70 years ago and that is a ludicrous model for us to follow today. When colleagues say” but your health insurance is so expensive to buy on your own” that is so inaccurate- health insurance costs what it costs, and if your salary is $10,000 lower so your employer can spend $10,000 for your policy, your employer did not save you anything. But they do get a savings if they present a pool of 3,000 mostly healthy people to be covered; which is why actuarially we need a diversified pool because if I am now pooled with more sick people when I buy on my own then that will surely increase my rate. At the end of the day, insurance is mostly just math about who gets sick and what it costs for treatment. And as long as employers get basically all the health people the individual market will always cost more.
7
@T. Turner Employers get a tax break for paying that 75% of the cost. They don't do it out of the goodness of their hearts.
12
Thank you much Dr. Krugman, for bringing to the public’s attention a very under-reported story. Besides providing essential health insurance to many more of its citizens, and at lower cost, the Democratic administration and legislature in Trenton serves as a pivotal nationwide example of the real world benefits to people in Republican controlled states in voting this moribund, unresponsive, and uncaring party out of office in those jurisdictions. It took the leavetaking of the historically unpopular Christie and his executive sycophants to allow this dramatic shift in New Jersey’s approach to healthcare. Hooray!
8
In this regard, and in light of New Mexico becoming an all blue state beginning January, the legislature and hopefully our new Governor Lujan-Grisham will consider the Health Security Act, legislation that would enable New Mexico to set up its own healthcare plan. Supporters say it would be set up like a cooperative, would cover most New Mexicans who choose to participate, would offer a comprehensive set of healthcare services and freedom to choose providers, and would be administratively simple while being paid for with existing monies from public funds, employer contributions and income-based premiums. Beginning January there will be virtually no Republican opposition in the states. This is the way it was done in Canada. First a number of Provinces set up their own health system and it then became federal.
16
I agree with about 86.2% of what Professor Krugman has presented in this op-ed. I will though give credit for not going off about single payer government financed health insurance, or "medicare for all," as the Radical Left demands. Does the Radical Left and their suppoters realize that medicare only reimburses up to 80% of the healthcare bill? What does the Radical Left propose to pay for the remaining 20%? See, this is the problem with the message of the Readical Left; it is incomplete, short on the facts, absent of truth, deliberately misleading, and just plain wrong, not at all American, not at all what the Founding Fathers had in mind when they created America. Do you have a problem with that? Thank you.
4
@Southern Boy: When you grow up to Medicare age, you will be bombarded with information from multiple insurance companies about policies to fill this 20% gap. Also, required premium payments to Medicare are means-adjusted, so people with higher incomes pay more.
10
@Southern Boy isn't it that Medicare pays only 80% for the same procedure? So in essence, the entire procedure is paid for just at 20% less than the private companies pay? They are able to set rates lower than private insurers because of their size and ability to negotiate...
5
@Southern Boy/
excellent thank you. But you merely point out that we need more education. That would be a fine step.
I know many senior folks who have Medicare and must find some kind of "supplement" plan to fill in for the 20% Medicare does not cover. And they can choose among many private companies for this. One plan for example covers the full 20% and is the most expensive and there are no deductibles. Another covers everything amd there is a $180 deductible for Part B Medicare (doctors). And then a few $20 co-pays. So one can probably find a plan one can afford and if not there are subsidies. The older you are the more it costs you in general for the 20% gap. And it goes up every year (point: buy it while you are first on Medicare). IT CAN BE DONE! IT CAN BE MODIFIED AND IT CAN WORK! This is American; wealthy, innovative America!
7
Americans support publicly financed health insurance on the principles of universality, accessibility, portability, comprehensiveness, cost efficiencies and public, non-profit administration. Progressive states will lead the way and ensure access to the medical community is an inalienable human right like public education is for our children and grandchildren. Everyone's been blessed with the gift of life, and disease can strike as randomly, and far more frequently, than fire or crime. We can become self-insured through public administration and protect everyone from a medical crisis as a human right regardless of wealth or employment.
Progressive taxation is the fairest way to finance public health insurance, so the CEO and janitor cleaning the office have equal access the medical community. Medicaid, for all its good intentions, is a welfare program that requires recipients remain paupers, a policy that depresses local economies and exacerbates an underground economy as the only means poor people can create a nest egg.
Many large corporations and public entities are self-insured, and it's not a heavy lift to create a public, self-insurance model that protects everyone against a medical crisis regardless wealth or employment. The issue is whether to pay under a single or multi-payer model through non-profit insurance. Americans should have the right to see any doctor accepting new patients and be admitted to any medical facility our doctors recommend. We can get it right.
10
All Republican moves on the ACA seem to target the price (up) and the viability (down) Obamacare.
When we separate the smear campaign against "Obamacare" from the real changes that the ACA implements (such as preexisting conditions), almost all people seem to like it a lot.
Virtually nobody outside the lobbying arm of the GOP wants to return to the preexisting conditions exemption days. Almost all of us have a preexisting condition.
The individual mandate is actually simply an extension of how insurance was sold to us in the first place; pooling the coverage to average out the costs and make them affordable.
That sounds like Democracy.
18
Democrats have been voted in time and again in the past 50 years and have never delivered on Health Care. Both parties are complicit in this mess. Why should voters believe it will be different now?
3
@Rahul
Democrats delivered Obamacare, over the concerted opposition of the entire Republican party. Thank you, Obama, and thank you Nancy Pelosi.
The ACA isn't perfect, but it is an ENORMOUS improvement over where we were before.
33
@Rahul I notice (as I'm sure you did) that your "50 years" time window reaches back almost - but not quite - to 1965, the year that Medicare was signed into law.
How convenient, to ignore the most significant advance in public health care of the 20th century... one which had Republicans setting their hair on fire and self-defenestrating from tall buildings.
The GOP has fought public health care tooth and nail every time the subject has come up. Would they overturn cars and set stores on fire to maintain fee-for-service? One wonders.
18
@Rahul I don’t understand have you been asleep. Under Obama a huge health care law was passed. Seriously have you not heard of ACA?
1
Simply pushing and pushing and pushing Medicare buy-in at a younger age in a unified voice from EVERY Democrat on EVERY media platform at EVERY opportunity, and passing a clear, simple bill in the House (and calling loud and clear, over and over again, to McConnell to allow a vote in the Senate) could either win the Senate and the Presidency for the Democrats in 2020 (if McConnell refuses to budge) or get a significant improvement in health care for Americans (if McConnell caves), or both.
Do it!
31
@Poet
I think Speaker Pelosi is going to send a deluge of bills the Senate way and corner republicans into being the blockers of any type of reform. We shall see if the press portrays it as such, or whether they will do the usual false equivalency at every turn.
At any rate, Single Payer is gathering steam (as true Progressive candidates were elected everywhere), and it is the defacto plank of the Democratic party. By 20' it will be on the ballot almost everywhere.
Time to join the rest of the industrialized world.
14
@The Poet McTeagle Great idea!
1
The rest of the world does NOT, repeat NOT, have single-payer systems. They have universal systems.
The idea of equal rights under the law is a linchpin of the Constitution. The law applies equally to all citizens. It would appear that the application of Medicaid violates the spirit of that law. Some states have it, others don't. It shouldn't be a choice. It should be uniform, one way or the other.
6
Country after country cover everyone, provide as good or better outcomes and make people happier with their care (by polls - despite the imperfections in each system) all at 40-60% less than the US and they all have several common key features we lack.
1) Everyone is covered and everyone pays in if they have an income.
2) Prices are for services and drugs tightly controlled based on value
It's going to be a heavy lift convincing people they do have to pay in all their lives - even though the rewards of being taken care of without financial hardships are great.
HC providers and drug companies will fight price controls tooth and nail.
Yet if we don't make these changes we will continue to see poor public health, high costs and increasing h/care related bankruptcies.
22
@Mark Mark: We owe our entire political gestalt to rentiers who want to profit from delivering services governments typically provide on a non-profit basis.
14
@Steve Bolger well said!
A bill to allow Medicare to negotiate drug prices would win over many GOP inclined elder voters and please the Democratic base. It would force McConnell to go against his base if he led a vote against it. The prices are not sustainable and in the long run this will happen. Trump would have to argue against the rest of the first world's ability to "negotiate", his supposed strength.
35
Indeed. I'm still shocked that the Dems didn't fight tooth and nail against that part of the bill. We found ourselves in the donut hole last month and it ain't cheap. Let the Ds admit their mistake fifteen years ago and make the necessary changes with their new House majority.
1
@poslug
Yes -- make the Republicans put up or shut up!
2
@poslug: Trump's "negotiation" style consists of being so obnoxious his targets will pay to be rid of him.
3
The most dramatic example of how this can be done is New Jersey, where Democrats ... promptly created state-level versions of both the mandate and reinsurance.
Who pays? Where does the $1500 savings come from? The great 'delivery' idea, is the federal government printing money to give to the insurance companies. Republicans should have though of that. Which would be playing ball in their yard with their umps. They would have thought of it, except Democrats would've sued to stop enriching the evil-conservative insurance companies -- thru a mandate.
2
@Jabin
Then why do all of those countries that do cover all their citizens and often non-citizens pay nearly half than we do?
17% of our GDP devoted to the private sector should cover manicures and pedicures while we wait for the doctor.
6
Paul,
All those sons of Mitches* - supporters of Sen. Mitch McConnell - would be taken down a notch if in 2020, one man is voted out of office. That man is...uh...well, Mitch McConnell. It might seem far fetched, but if the low income voters in the eastern part of his state realize that he will take away the health insurance that many of them desperately need, then who knows.
*I know, I know, many of his supporters are women, but sons and daughters of Mitches doesn't work as well.
11
The trouble with year-to-year health insurance coverage is the fact that people tend to need the most health care when they are either too young or too old to be gainfully employed to pay premiums.
9
@Steve Bolger
Which is why we average out the costs.
1
Odd that an economist like Krugman would miss one very important fact: The ACA is primarily meant to serve those who qualify for subsidized care, and it's success is predicated on the assumption that enough people who do not qualify for subsidy will sign at at high(yes, high) premium cost to pay for the rest.
Well, we all know that did not materialize, and insurance carriers have been dropping out of the program as a result.
In short, we need a completely new and viable economic if we are to truly have 'universal' healthcare, as well as a willingness for taxpayers to fund it. How Krugman could miss this is beyond me.
6
Did he miss it?
“Now that Democrats have won control of multiple states, they can and should emulate New Jersey’s example, and move beyond it if they can. Why not, for example, introduce state-level public options — actuarially sound government plans — as alternatives to private insurance?”
The reality is that nothing material can be achieved at the Federal level.
14
@Steven Robinson
This is the blind spot of Obamacare supporters. There are millions of Americans now occupying that blind spot.
4
@Steven Robinson: Health care is a really lousy insurance business because there is little people can do to reduce their risk of needing it, and cherry-picking people to insure is prohibited.
1
IF our leaders still think that they can satisfy the useless insurance industry and still compromise with them we will never have real change. The insurance companies have brought all this upon themselves and I don't care if they go out of business because their business is to be the primary cause of bankruptcy by never honoring their own contracts.
38
@joe Hall The two major pigs at the trough are the insurance companies and the pharmaceutical companies. With single payer insurance/Medicare for all, the obscene profiteering in those two cabals will end, and a lot of the money that they are taking from the system can be redirected to actually providing care for people, and the medications that they need.
1
@joe Hall
Hogwash: "...never honoring their own contracts."
The Obamacare repeal did not fail because the republicans had no plan to replace it. Their plan was to go back to what we had before it passed. It failed because John McCain was in one of his cranky moods and decided to stick it to his fellow republicans
4
@sr
You might contemplate the fact that he had a brain tumor gave him a different perspective on the importance of access to health care for all. Rather than "cranky moods", I think that words like compassion and empathy are better attributes for John McCain's mood. I would also attribute his motives to placing welfare of the people of the USA above his party, something he was known for during his long and distinguished career.
22
Going back to what we had before the ACA is not a plan, it is a death wish. Before the ACA, the headlines year after year were about soaring healthcare insurance premiums or coverage unavailable altogether. The headlines year after year were stories of coverage denied for those who thought they had insurance only to find out that the carriers had no intention of paying. The headlines were about personal bankruptcies due to health setbacks. The headlines year after year were about the lack of routine preventive care for large numbers of poor people and the consequences to them in the longer term. The headlines year after year were about women being denied coverage for the challenges they face daily, like contraception, prenatal and maternal care.
So, literally, going back to before the ACA is a death wish. It is a wish by the GOP for poor healthcare for millions of Americans, leading to premature deaths and miserable lives. That it is also a death wish for their political party is only fitting.
9
@Gregory L. Barkley
On the other hand, McCain supported the Republican tax cut that is going to raise the deficit and debt after decrying the debt during Obama even though Obama was bringing down the $1.4 Trillion deficit by 2/3 that W Bush gave him.
McCain voted yes in the preliminary vote December 2. He was too sick to vote for the final vote.
Probably not a coincidence that the tax bill helps his wealthy wife and children.
1
One of the interesting and elucidating aspects of Paul’s opinion columns is his rather slavish devotion to establishment Democrats, not just—but exemplified by—Hilary Clinton and Nancy Pelosi. He seems unable to break out of his cocoon of establishment loyalty (and perhaps his enduring dream of being chair of the CEA if not Treasury secretary) and actually look at the reality of Democratic (and democratic) politics. Paul’s support of Hilary in the 2016 primaries was unwavering (note to Paul: she lost the most winnable election for a Democrat since 1932) , as his current obeisance to the current House antiquarian leadership. Perhaps Paul could be reminded that, even maybe at Princeton, relief from the pain of beating your head against a wall ends only when you stop beating your head against a wall.
8
@Steve Collins
Your ad hominem attack ignores the possibility that this is actually the way he feels. Your rant seems to indicate that you have some strong feelings as well. You have attacked three people without actually addressing a viable point.
By the way, Hillary actually won the popular vote by 2 million votes.
1
Does no one notice the irony that the number one issue the democratic party ran on this midterm cycle was fixing healthcare....and the current system is a 100% democrat-owned law? How ironic. They pass a landmark law, and then run on fixing the mess it created. Yeah sure, you did such a great job the first go-round.
7
The good thing is that the Dems acknowledge that fact rather than blame others for the flaws in ACA. Quite refreshing considering the blame game we've be subjected to for two years. That the GOP chose to be wreckers and decline to work to make the program more efficient is another story.
How can any political party claim to represent "hard working Americans" when they've sued to end something so crucial as preexisting medical conditions?
21
@DanielMarcMD The Democrats never said the law was perfect. There was a need for fixes. But the Republicans refused to look at ways to fix the shortcomings, and instead focused on throwing the baby out with the bath water. And went even further cutting out key portions of the law to make the problems worse.
In the meantime, having no viable alternative to replace it with if they had succeeded.
It would take an entire column for me to give the details of how this happened.
24
@DanielMarcMD
The mess Democrats created? Are you being dishonest or ignorant? The Republicans wrecked it as much as they could. Did you not read the article or are you hoping no one else did?
7
It’s been said of Germans that they wanted Hitler, they got Hitler and they liked Hitler.
Tragically, the same thing can now be said of us.
Getting rid of Trumpism -- or at least maintaining it as a sort of Devil’s Island reserved for kooks and malcontents in need of close, careful watching -- will be a long, hard slog; although there are such things as self-limiting diseases, Trumpism is not one of them, so it will take someone physically appealing, idealistic, young in spirit, tough-minded, pitiless, cruel and ruthless to start us on our way.
Obviously, someone who doesn’t think in traditional political party terms.
There are a number of possibilities.
An outsider, a Robert Kennedy, another Barack, maybe a Beto, maybe a woman, though I don’t see one on the horizon yet, someone moderate-center-right who is obsessed with fixing things, is willing to gamble on Medicare-for-all and a limited program of income supports; and is not adverse to abandoning failed programs like tax relief for billionaires as a means of controlling the national debt.
A President who values business, but insists on shuffling the cards when dealing with business people.
A President open to bringing in an experienced hand like Michael Bloomberg to help him run things.
Hillary would have been very good, but regrettably the time for that has now passed us by. Although a seat for her on the Supreme Court remains an interesting possibility.
Beto and Bloomberg. That, in fact, is not a bad idea.
16
@A. Stanton: I am entirely with you on every point^. Thank you!
1
Letting the states try to make the ACA work or nibble away at it like rats on cheese still depends on which party controls what state. The only way to achieve universal health care AND cut costs is a single-payer system that takes the business out of health care by eliminating the middlemen -- i.e. insurance companies and medical billing firms -- while letting the government set prices for drugs, medical procedures and hospital stays. Whatever tax increase would be needed to pay for it is miniscule compared to what Americans or their employers now pay in insurance premiums.
20
@Christy: Ultimately that would be the way to go, but on the way to that goal, many states have a large enough population to set their own health care and insurance & health taxing policies. Denemark, Finland and Norway for instance, have fewer than 6 Million inhabitants each, Sweden fewer than 10 Million. New York City alone has almost 9 Million living there, and could well afford to have its own health care system for all its inhabitants. Governors of "health care for all"-friendly states could form a task group to study European style health care approaches and adopt the one that suits their state best. Very small states could unite with larger states under one health care umbrella. There will still be people needed to manage state or government run systems, but the profit motive needs to be removed from health care. Like public education, it should not be a profit-driven enterprise. A healthy and well-educated populace is an interest and a gain in itself for any country, and worthy the investment in taxes and personnel, which can be done cheaper than what we have now, as evidenced by Europe (and Canada and Australia).
6
@Christy
You make some very viable points but the very powerful Health Insurance Companies have amassed a lot of wealth from profit, they are not going to go gently into that good night. That is the reason that Obamacare was created, they were able to enlist the aid of Insurance Companies that really was a big part of making it work. Possibly under this reality if Obamacare survives and regain some of it's coverage the next step would be to expand Medicare to commence at 55.
In my opinion, Obamacare was an excellent beginning from nothing, nothing is what we had and the Republicans would prefer that option.
Until our Representatives can actually preform the people's business and contemplate, discuss, debate and compromise, we will have no sustainable Healthcare in America.
PS billing firms have no impact on the cost, they only report the ICD 10 codes to the insurance providers. These codes are assigned rigorously and must be substantiated from the documentation within actual Patient Medical Record.
3
Health care is a common good like public safety and public education. Operational control should reside at the state level, with performance standards being a joint state-federal responsibility.
3
Why not one national healthcare policy for one nation?
"Life, liberty, and the pursuit of happiness" provides sufficient justification for such.
8
@Frank
Health care is a service offered mostly provided by private citizens. They are not government employees who you can dictate to. If you want them to be gov. employees, then you will pay not only the salary, but benefits (pension and healthcare for life). Government employees are very, very expensive. Especially the highly educated get a pension multiples of social security.
Universal health care coverage. Definition: No one having crushing chest pain should have to think twice about calling 911 because of fear of what the care could cost. No hospital providing such care should have to think twice about whether it will be fully reimbursed for providing the needed care.
58
Tell that to the MD from Virginia!
1
@PETER EBENSTEIN MD
Fully reimbursed? The government doesn't fully reimburse anything in healthcare.
@Driven "Fully" is shorthand for a complicated subject. The point is that hospitals, required by law to provide care to all comers, cannot be allowed to go bankrupt as a result.
2
What many of wish for, Paul, is a health care plan wherein we don't hear another "Pass it and then we will know what it means," a la Pelosi. Yes we need more and better healthcare.
No, it won't be more and better unless both major parties sit down and practice what used to be called, politicking.
One-sided politics will never deliver a healthcare plan for both sides.
5
@Lake Woebegoner: That's not what Pelosi meant and said. Pelosi was responsible to navigate the ACA through Congress, a huge achievement! And currently, enough Americans have indeed come to understand what it means and they like it much better than what they had: e.g., being refused for pre-existing conditions, or kicked out or have their premiums increased if they actually used their insurance. Or having to beg for charity at the entrance of the local supermarket to cover the medical bills for a child with a serious illness. Most Americans don't want to go back to pre-ACA times, even if they want improvements or single payer.
9
@Lake Woebegoner. Even our current commander in chief admitted health care was complicated. When Pelosi said that I'm sure she was referring to the fact that issues would reveal themselves and fixes would need to be addressed. Republicans, having regained some control refused to do so. Instead voting over 50 times for complete repeal instead.
8
@Lake Woebegoner
Did you also complain when Republicans passed their last tax bill and wouldn't even allow time for Senators to read the bill.
Democrats complained they were given the bill a couple of hours before the vote.
And Republicans were fine voting yes without knowing what was in the bill.
7
Here is a real shortcut if a state wants to improve the economics of the ACA plans:
1. Mandate that all payers with ACA plans cannot pay more than 150% of Medicare for health services.
2. If the hospital's balk, begin taxing them as if they are for profit hospitals for terms of both corporate tax and real estate taxes.
And watch premiums drop by at least 50%.
9
Mike, please show me one health plan that pays 150% or more of the Medicare fee schedule for anything. Most Health plans contracted rates or "fee schedules" are at or slightly above the Medicare fee schedule. Only out of network fees exceed 150% of Medicare fees. These out of network fees are generally subject to large deductibles before any money is paid out by the insurance company.
@Mike
My guess is that a bigger part of the problem is that we pay more for hospitals, doctors, tests, etc. than other countries.
Insurance companies just put their profit margin on top of those costs.
We can cut out the insurance company middle man but my guess is that is just cutting out their 10% profit and maybe a few percent more for other things.
It happens to be a very Republican idea to give more power to the states. In the case of health care I could not agree more. The problem however with New Jersey and 'reinsurance' etc is that while it provides increasing amounts of health insurance it is extremely expensive and most money goes to the private for-profit insurance industry. When the industry complains about too much risk we have to promise them billions in tax payer money to keep premiums from skyrocketing. Has anyone else noticed that they have a noose around our neck? They know that there is nothing we can do to avoid our dependence on their industry because government is a dirty word and Medicare-for-all is off the table. Or is it? Maybe some states could try some actual innovation and eliminate private insurance. It costs much less and provides better care and outcomes.
31
understanding the heathcare situation in the US is not that hard: it is organized primarily around the opportunities to profit, mainly from somebody else's bad luck. it is about business and not health, profits and not people.
fixing the situation is much, much more difficult, especially with Republicans on the job, since they always put profts before people.
42
Paul Krugman's suggestion that the Democrats start with implement better health care insurance at the state level is sage advice - that's how Canada implemented their system, against enormous corporate opposition.
In Canada, Saskatchewan played the role that Massachusetts is playing in the US, bring in universal coverage early, and then other provinces followed. The Canadian federal government got involved once the public support for universal coverage appeared, to ensure that there was a consistent minimum standard of care across the country.
That's still the case - the provinces run universal health insurance coverage in Canada, with the only federal involvement being top-up payments, which are dependent on the provincial systems meeting certain negotiated minimum standards of care. In some provinces, universal health insurance coverage is actually run by a private insurer, under contract to the province.
Having each US state run its own system, to meet local needs and conditions, and to let competitive contracts for private and non-profit corporations to administer the insurance and run the health care facilities, is a brilliant idea. Restrict the federal presence to ensuring financial stability, portability between states, and minimum standards, and let the state governments get on with running a local system.
19
As always with Krugman--the Pied Piper of Fake Economics, he likes to cherry pick his facts. New Jersey is a fiscal basket-case. It's unfunded liabilities make it among the walking dead of bankrupt states--along with Connecticut, Illinois, California--and assorted other blue states.
But let's talk about Vermont, Mr. Krugman. Can we? Here we have a solidly liberal legislature, in arguably one of the most socialist-friendly places in the nation. Bernie Sanders, anyone? We also have (according to NIH ratings), one of the smallest, healthiest, and most active populations in the country.
Yet, when we tried to pull off single-payer, which is the ultimate goal of Progressives like Krugman, it was determined that nothing less than a doubling of State taxes would be required to pull it off. Even with a desperately committed Democrat governor, and a solidly Democrat legislature at the time, single-payer was found to be economically--and therefore politically unviable.
Democrats can deliver on health care, Mr. Krugman, if they want to drive their states even further down a financial rat-hole. Add to the equation, that blue states will always want to provide free health care to illegal aliens--and the story becomes yet more bleak. For as the brilliant economist, Milton Friedman was fond of saying, "You can't have open borders and a welfare state".
6
@Jesse The Conservative: Yes, of course taxes would go up, but these would be offset by reduction or elimination of private health insurance premiums.
37
@Jesse The Conservative
Jesse, while Vermont certainly is a bastion of progressives, and progressive right thinking, perhaps it should look to it's wiser older brother, Massachusetts, where Romney care has been working extremely well for YEARS! And please notice, it NOT double the tax rate in Massachusetts.
Determined people can get almost anything done if they want to; it's the nay-sayers like you, perennially dragging their ideological heels, that usually bollox up the work for the rest of us, and in this case, keep us locked into an ineffective, inefficient, third-world like health care system, where the corporate healthcare insurance overlords always seem to have the last laugh.
Time to roll up your sleeves and get this done, or please, simply get the heck out of the way!
21
@Jesse The Conservative
Straw man. Nothing in this article said states need to go single-payer to effectively implement the Affordable Care Act.
9
Although Democratic controlled congress won't pass new legislation on healthcare reform in the coming years, but they can force the budget into more friendly to social programs and infrastructure rebuilt. The other thing they can do is to re-establish pro-choice and gun controlled agenda.
2
@Usok: The average public cost for shootings in the US almost certainly exceeds $1 million per incident.
10
I’d like to see our three West Coast states take advantage of their current Democrat-run governments and their combined buying power to create a regional single-payer health care system, or a shared public option approach. There is enough data now to lead to a successful implementation.
35
Mr. Krugman distorts the issue, stating that 'trump was remarkably absent from Democratic messaging'. What "Democrats" of all kinds, not just politicians, object to is the media, including the NY Times as well as television news. every day heaping column after column, story after story, on trump's doings, his family and his cohorts. While a statement of criticism should be uttered, more, much more time should be devoted to issues. devoted, yes, to healthcare, a minimum wage, control of the crooked banks that brought about the debacle of '08, and free college tuition at state colleges. Had this emphasis been part of the Democratic agenda in '08, certainly those frustrated citizens who turned to a demagogue, as they are doing all over Europe today, and for the same reason, neglect of the issues, would have voted Democratic.
7
@JFP
There is no greater issue than the threat to Democracy posed by the rising authoritarianism, denigration of facts and reason, loss of judicial independence, and breakdown of basic civility. All other issues are important, but secondary.
5
The best hope to improve Health Care in America is to vote in Democrats, not just this year, but every year. Voters tend to flip flop, and put to the test ( and in absence of a crises,) tend to vote republican because republicans promise to lower their taxes. The problem is always going to be the voters, the young voters-the ones below 30 years old don't care about Health Care because they are in their healthy years. The old voters don't care about Health Care ( because the democrats gave them Medicare a long time ago)so they got theirs. The poor have Medicaid, So you are left with a segment of voters between 40-65 to care about the issue. Many of these people have great Health care plans given to them by their employers. The ACA was great because it solved two big issues, preexisting conditions, and putting a cap on how much out of pocket you could be held accountable for, it also it paid for itself. The republicans as a group have voted against every program that improved the quality of life and eased everyday fears of Americans. They fought to the death to stop social security, just as they fought to the death to repeal the ACA. Republicans get re-elected by promising to protects gun rights, lower taxes and in recent years stop illegal immigration. So in the end its up to the voters and nobody else. It's time to have a national debate on Health Care and see exactly what the voters want. Go to every State and ask them.
12
It's shocking how determined some state's elites are to keep their struggling populations suffering and "in their place"-- so much so that they are willing to decline "free" money.
Also refusing to spend on education, and putting up roadblocks to voting rights--the visceral hatred those state's elite's have of a large chunk of their own state's population is painfully clear.
12
Obamacare is primarily Medicaid. Stop pretending it's been anything other than this. All those who earn too much to receive Medicaid or federal subsidies of their premiums, have been severely disadvantaged by Obamacare. What good are all those added benefits if you cannot even afford the out-of-pockets.
7
@AACNY: I don't think saboteurs of programs have a leg to stand on when criticizing them.
3
@AACNY
Illogical. Obamacare allows states to expand eligibility to Medicaid. There will always be people “just above” whatever threshold you set. Is that a good reason to keep the threshold lower?
3
@LV
Again, there's that Obamacare blind spot through which a Mack truck could be driven.
Let's just admit Obamacare expanded the number of insured by moving people onto Medicaid. What's never been answered is why everyone else's situation had to be so adversely affected just to put people on Medicaid.
1
Our Governor elect Jared Polis has promised that healthcare is the top of his agenda so I look forward to a much better situation than exists now as costs are very high here.
7
In this column you will find irrefutable proof that Krugman is a neoliberal with some conscience. When everyone has moved on to talking about Single Payer and Universal Healthcare, Krugman first shushes Seth Moulton to show to everyone whose side he (Krugman) is on - "I am with Pelosi, wheeee!". Second he mounts his worn out 'market-based' solutions footstool and proceeds to preach his now worn, familiar and dog-eared sermon on Obamacare. In the last two lines he doffs his cap to the 'Public Option' but even here his caution is laughable. Witness how the eminent Doctor, wants the public option to be launched ONLY in Democrat-held states. One wonders if these states really need his advocacy. It leads me to suspect if he threw this in so that in later columns he can claim, 'I have always supported the Public Option!'. I used to be his fan and read his books aeons ago before I really read up on the neoliberal disease. He suffers the standard Nelson's eye of Economists concerning the Healthcare market. All the consolidation amongst the insurance companies and providers turning the market into an Oligopoly in the last decade are not his problem. Krugman is a garden variety neoliberal 'Thought Leader'. He is the 'leader' of thoughts that always favor Corporations and Markets overthe public good.
9
@Paul Art
Did you even read this? The reason he recommends Dem. states takes action is that Republicans won't, and no action will be taken on the federal level.
6
A state-level public option, that's a wonderful idea!
It would also help people who don't do their homework, such as Seth Moulton and part of the progressives in this country, to see that Democrats ARE serious when it comes to a public option.
Of course, those who did their homework know for almost a decade now that it's precisely Pelosi who has been the only Speaker in history to have been able to get a HC bill passed in the House that included a public option.
And they know that the overall popularity of a public option went up considerably precisely thanks to Obama campaigning all over the country, explaining what it is and why it is so important.
And they know that the entire Democratic Senate ended up supporting it too and including it into their final version of the bill - it was taken out by Independent Joe Lieberman, who has once been considered as a potential VP candidate for ... John McCain.
Finally, it's ABSURD to imagine that "Democrats need to have a positive agenda". Anybody who paid attention during the years that they controlled DC and afterwards, both under Obama and now under Trump, can perfectly see what that positive agenda is. No need to prove anything anymore, just time to allow them to move forward again, rather than staying home ... !
Of course we have to clean DC from the utterly corrupt GOP. That in itself IS a very positive thing to do. But with a clear majority of the American people supporting the Democrats' agenda, it's only a start.
3
Prescription drug advertising is so pervasive and repetitious it has to cost $billions. Viewers and readers are numb to it all. It has to be an industry bribe to media because it makes no economic sense otherwise.
I must have seen that dumb ad for Otezla 1000 times.
15
@Steve Bolger
Same with the ads about Medicare enrollment. They are not quite as stupidbut the amount of ad's in astounding. Not really productive.
1
@stever: The more we pay for internet access, the more ads we see on the TV channels we are obliged to pay for to get it.
3
@Steve Bolger I named my cat Otezla.
1
I am still not convinced Republicans ' zeal to destroy the ACA was actually about getting rid of the program. it seems to me it was far more important to be seen as trying to undo it, hence the twin-pronged approach of repeated, noisy campaigns and multiple losing votes... and reluctance to come up with any alternatives.
it was all for show: opposition to anything and everything associated with that "liberal", black, one term President who gave them such an appealing target to fight against,oart if a strategy to consolidate their base.
these guys will play politics with anything, even matters of life and death.
12
Perhaps it is time to examine in minute detail how Medicare and Social Security works for those who are lucky enough to be on Medicare and collect Social Security benefits. How much is paid into the system and how much is paid out for claims. How much money has Congress managed to use for other reasons than retirees benefits.
Included in the information should also be an explanation as to why Medicare has chosen to hire a 3rd Party company to be involved in Medicare situations and how much they are paid.
From this information regular people, as well as economists and Congress will have the full picture of how Social Security and Medicare operate.
Next we can examine if we do away with the Cap of $123,000 salary how much that will add yearly to the Fund.
After this amount is established, find out from Corporate America how much it donates towards Health Benefits for their employees. This expense would go away
Then consider rounding the FICA tax up to 8% from both employer and employees.
When this exercise is completed, all concerned, Citizens, Congress, Economists and Corporate America will have the information we need to make an informed decision regarding if Medicare for All should be adopted.
Don’t worry about private insurers, they don’t worry about patients. The wealthy will still have the option of private insurance
As for job loss, the Social Security Administration will have plenty of job opportunities.
I will be happy to join others in doing the analysis.
18
If we had waited on the Republicans to pass Social Security and Medicare, we would still be waiting. Same thing with universal healthcare.
18
Mr. Krugman, as usual, provides only his side of the story to validate his opinion. New Jersey’s a financial train wreck waiting to happen because it’s spending and budget is out of control -including its healthcare program.
Several insurers have pulled out of the ACA in NJ; UnitedHealthcare Co., announced it was pulling out of New Jersey's health exchange. The latest departure signals a need to repeal Obamacare, according to Erica Jedynak, state director for the conservative group Americans for Prosperity.
"The collapse of the Health Republic Insurance of New Jersey is the latest example of how Obamacare is unaffordable, unworkable and hurting the American people," Jedynak said. "
The state’s estimated unfunded liability is now $90 billion, $10 billion more than in 2014,
The state has $171.6 billion in long-term debt, up from $3.3 billion the year before. State officials projected $3.7 billion in debt service payments this year. The State is on track for a $2.4 billion deficit in 2018.
Record unfunded pension liability, record deficit, record debt, unsustainable health care with insurers leaving ACA and families without insurance coverage.
I wouldn’t use New Jersey as your example Mr. Krugman….you got a problem with that.
4
@JMS
Christie left a mess then?
14
@JMS: Is "prosperity" rent-collection by oligopolies in the US?
3
@Matt
Er...were CA an independent sovereign state it's economy would be the 5th largest in the world so about the same size as that of Britain. Britain's debt is around 1.8 trillion sterling or about 2.4 trillion dollars. It's also a huge net contributor to the federal budget unlike Arkansas. Economics isn't really your thing is it?
8
Paul Krugman left out some key information in his comments for California, New Jersey and North Carolina. Here are some facts:
California State Tax 13.3%, Sales Tax 7.25
New Jersey State Tax 8.97, Sales Tax 6.625
North Carolina State Tax 5.499, Sales Tax 4.75
Nothing is "free"..
2
@Martin
Sure there are no free lunches. But Americans are willing to pay for public services. And isn't CA's economy the largest in the nation and doing quite well?
13
What's the infant mortality in NC How about maternal death? How about uninsured? And NC isn't the sixth largest economy in the world. With a 14 bill surplus
4
@John
I lived in California in the 1970's when it was affordable. No More.
1
I think Krugman should be the first to wait for 10 hours in the emergency room or wait a month to have a MRI read or get a letter in the mail reminding him of an appointment months form now. Even Sweden has allowed private insurance to return and has over a million folks paying premiums privately now because they refused to put up with the inefficiency of the single payer system.. Socialism is stealing and the only way for the Socialists to control costs is to ration healthcare. When government controls medicine it controls who will be doctors, what facilities get built, how much is charged and basically ,wrecks the system with its bureaucracy . There is nothing new or innovative about it and it imposes another level of governmental control on people which is of course the real reason the far left socialist Krugman pushes it.
2
@James: All those systems you call rip-offs deliver better public health results by standard measures than the US system.
6
@James your post is inflammatory and completely, 100% incorrect. What Medicare for all proponents are suggesting is a common INSURANCE program, called MEDICARE, that covers everyone. This is not socialism, any more than your Mortgage insurance, Car insurance, Dental insurance, or for that matter, FDIC bank insurance is socialism. And Yes, just like your car insurance, this insurance would demand certain standards of care. When was the last time someone used bad parts when repairing your car? Never? You can thank your insurance company for that.
I know, facts are tricky things for you. But if you are so against these ideas, go live in a banana republic somewhere, instead of trying to turn my country into one.
9
@James I think you should be the first to lose your insurance altogether. That way you won't have to wait for 10 hours in the emergency room or get a letter reminding oyu of an appointment month 'form' now. You won't get any care at all with NO insurance.
8
The most important thing that the Democratic house can do is to pass a bill allowing the importation of drugs from Canada and
other reliable countries and take all steps necessary to bring down the cost of drugs. You can tinker with all the insurance plans in the country but this does not change the basic fact that drug costs are too high. Once costs are reduced it will be much easier to offer medical insurance at reasonable rates. By the way President Trump supports the concept
12
Paul jumps over the impressive fact that NC reduced uninsured by 5% without any expansion of the expensive Federal programs. I wonder what innovations states could have accomplished with the same money outside of the ACA straight jacket.
2
@Pat
That's not correct of course.
The only thing that NC didn't do is expanding Medicare (and soon its citizens will force their GOP leaders to do so too, obviously, as they did in many other red states already).
That lowers the number of uninsured people, of course, but it doesn't take away all the positive effects of the rest of Obamacare (more than a 1,000 pages, remember?), and THAT is why the number of uninsured people went down by 5%.
Obamacare installs a marketplace, where people buying insurance on their own can now for the first time easily compare private health insurance companies' plans and prices. In other words, it INCREASES competition on the private market, you see?
At the same time, it indeed mandates insurers to no longer drop sick people - as all civilized countries do, of course.
Finally, as the CBO had calculated and all studies show, it curbs cost increases, both for the federal government and for ordinary citizens.
And then there's the TRULY "impressive fact" that it saves an additional 40,000 American lives a year. That's half a million American lives saved a decade (= very soon).
And IF you would have read the bill, or would have read this op-ed carefully, you would have known that it does NOT impose a "straight jacket", but explicitly allows states to innovate and come up with alternative HC systems. All that is required is performing better than the ACA.
Needless to add that NC nor the GOP in DC even tried to come up with a plan ...
11
https://www.newsobserver.com/news/business/article25434172.html
other factors include the improving economy which saw people return to jobs with health insurance and the new ACA subsidies which made health insurance affordable. this may explain the 5% drop.
2
@Pat Why not pursue both ideas?
1
Good to hear state ACA can save money but how can economist ignore the main cost source, the high cost of health care?
Do you know anyone who went to the ER, hospitalized for a week and went home with a bill less than $100,000? I've seen such bills, docs bill $1000 for unnecessary, multiple visits. NYT writer said his diabetic medications.
Do you own a car, is it a necessity? Yes? Should the govt provide everyone with an average car, and pay $300k for each one? Or food, $300 day?
They say for politics "it's the economy" but I find it hard to believe most who voted for Trump did so because they worked hard, paid modestly for employee health care, excessively for deductibles co-pays and family coverage. And resented also paying for nonworkers getting unlimited free health care (as they would if they bought $30k cars and had to pay for nbrs got free $300k cars )
But many reputable reporters say that feeling elected Trump.
A solution would be basic care are drugs from the govt with the freedom to get private care and insurance (like education here or foreign health care.)
I am leery of this prescription sounding an awful lot like what divided democrats and gave us trump, sounding like Hillary's asking the same people to have to wait and be sensible--again.
I wouldn't mind if it were the people who are doing ok to be asked to wait for once. No, no, it's the people who were never helped by the remedies that came too little too late to save the economy. In other words, this has no positive messaging for working class democrats and therefore, most certainly not for trump leaning working whites who are the ones democrats need most to sway.
It's the people bouncing between medicaid and Obamacare, one day off or an extra shift or two enough for the state to kick them off whatever plan they are on, even demanding disgorging of money if it's the case of making a nickel too much one month.
Paul, you're a macro guy. I humbly but ardently submit that you have no idea what healthcare is like on the ground, the meat ground into your statistics. If you had, you would never, ever promote the ideas you did today ever again.
8
All other industrialized countries have some form of universal government run health care, mostly single payor. They get better care as measured by all 16 of the bottom line public health statistics, and they do it at 40% of the cost per person. If our system were as efficient, we would save over $1.5 TRILLION each year.
www.pnhp.org & www.oecd.org & especially https://www.oecd-ilibrary.org/social-issues-migration-health/data/oecd-health-statistics_health-data-en
Some data:
Here are the per capita figures for health care costs in 2016 in PPP dollars:
US - 9507.2
Austria - 5227.3
Belgium - 4839.8
France - 4500.4
Germany - 5550.6
Luxembourg - 7462.8
The Netherlands - 5385.4
Switzerland - 7919.0
Sweden - 5487.5
Denmark - 5199.3
UK - 4192.5
Canada - 4643.7
OECD Average - 4003
Let's compare some bottom line statistics between the US and the UK which has real socialized medicine.
Life expectancy at birth: UK - 81.1 US - 78.8
Infant Mortality (Deaths per 1,000): UK - 3.8 US - 6.0
Maternal Mortality (WHO): UK - 9 US - 14
As Einstein said,
"The difference between genius and stupidity is that genius has its limits."
31
@Len Charlap - I agree with the overall sentiment that the US is not getting good value for its money, but the outcomes sited are not a good apples to apples comparison since the US has a different racial composition and a higher level of immigrants. There are centralized healthcare system in Europe like UK and France, and decentralized regional healthcare systems like Spain, Sweden and Italy (who achieve good outcomes as well). The US may look to the decentralized systems as a better guide forward.
2
@Len Charlap
Finally! A comment that actually made sense, and had data to back it up. Thanks for the link!
7
@Len Charlap. We know that, according to the World Health Organization, the US ranks somewhere around 35th among developed nations in quality of health care. This reflects both substandard outcomes, due to poor access to care, and excessive cost. Virtually all countries ranked ahead of us provide universal health care to their citizens at a fraction of the cost that our for profit system provides, and somehow can afford the associated costs, despite lower per capital GDP. In short, our health care system is driven by the interests of private, for profit insurance and pharmaceutical companies, and not by the medical needs of American citizens. Medicare serves the sickest and neediest segment of our population with the highest quality and most affordable care. It is government administered and universal. Case closed.
10
Healthcare is like every other calamity in life: You don’t know how it affects you until it does. If you’re young and healthy, being told you need to contribute to a program “in case you get ill” is a non-starter. That’s like telling an 18 year old who just got their first job “You need to save for retirement.”
Society has to be the adult in the room. “Father knows Best” was more true than a TV show. It morphed knowledge into wisdom, and that only comes with time and experience.
Here is an example from my past! I just turned 80 last month. When I was growing up, we didn’t have so-called “Healthcare.”
We had FAMILY! If one or our parents, or grandparents got ill, they moved in with us or we just took turns taking care of them. Many times, all of our relatives lived within walking distance of each other. What a novel idea.
Today, it’s almost the opposite. Families are scattered all over the country. Now it’s up to the government to come up with plans on how to take care of healthcare. The problem here is that in most cases, the people in charge of doing that are already taken care of because of their own personal wealth, or insurance plans given as “Bennies” for government employees.
So–how do we handle it now? By voting, not as a Democrat, Republican or Independent, but voting for the best idea, regardless of the party. Make the PARTY join the INDIVIDUAL instead of vice-versa.
6
My former neighbors moved from NJ to Atlanta about 3 1/2 years ago. He is in the IT business. I guess he was a contractor, but he invented something and most of his team was here in Atlanta. So after a while he moved the family here and they bought a house. They have a child that is medically fragile.
Their Obamacare policy that they had bought for the family based in NJ allowed them to going to any doctors inside and outside of network. But after two years of having an Atlanta address their policy and all the bills being from Atlanta providers they were told they were going to be dropped.
For 2018, in Metro Atlanta the only Market place providers were Kaiser an HMO and Ambetter ( which is worthless joke insurance). My neighbor told me that she found some other non Marketplace policy but it was going to be $68k for two adults about 45-48 yrs, 18yr at NYU, 17 yr, 12, 10 ( the one kid being at NYU is was another problem with the Kaiser policy).
So she priced moving back to NJ in Bergen County in 2018 in it was $24k. They figured the husband could commute to his job in Atlanta. They will be at $21,840 which is significant.
Meanwhile, the fools in rural Georgia decided to vote against their own interest since their still raciest Bigots and couldn’t vote for a Black woman and expanding Medicaid. So BCBS decided that they would add back BCBS to blue metro atlanta but cut it out of rural Georgia.
8
@MJS
I was dropped by my insurer and I live in New York. Oh, and by the way, I have no out-of-network coverage. It wasn't I who voted against my interests causing me to lose my doctors, hospitals and plan.
1
Remember: They are all hard working judges, "not Republican leaning"
2
As a person who votes for Democrats, and works in the insurance industry, let me suggest we need to change key elements of how insurance is structured for middle class folks. We need to drop the high deductibles that make a family spend $3000 - $6000 before coverage kicks in. This is especially true of accidents and non chronic illnesses. I had both last year (dislocated elbow and a brief "collapse" that require an ER visit). At 67, these events happen. One cannot set up a fund for the unexpected.
We also need to halt the privatization of health care, as formally non profit hospitals became parts of large for profit networks.
The ACA works best for the working class. It is terrible for those of us who are doing better (but at not wealthy).
18
@Terry McKenna
Obamacare supporters just ignore the cohort right above the subsidy levels. Democrats did this at their peril and received that shellacking.
Healthcare is one of those very selfish needs. As long as people have the care they need, they care little for anyone else. In the case of Obamacare, those who receive subsidies or received Medicaid just tell themselves it's working great and everyone else must have had a junk policy or blame insurers. In other words, they rationalize why it's not working for everyone else as long as it works for themselves.
2
Since solutions seem to bring the antidote to Trump, good ideas for healthcare need to made public, lower defense spending, trim some waste, a fair tax scenario, shore up social security, provide student loan relief, college tuition and slow down the deficits. Deficits will cripple social programs the republicans know and count on this. Lots to do without taking about Trump.
9
@dave - The phrase "lower defense spending" is an automatic non-starter for many on the right/conservativess. Health care IS part if defense spending. It allows a sufficient, healthy pool of people available, if necessary, to expand the standing army in time of crisis, or to shift to support "the war effort" as was done in WWII.
The Department of Defense has stated that obesity is a readiness issue. Obesity is one part of the health care issue that could have a negative impact on national readiness. An expanded health care system that covers everyone would help address that.
2
The most important action the House can take is to pass a budget before March 20, 2019. That would show voters that Democrats are united and able to run a no-nonsense government.
That budget ought to deal with healthcare in a straightforward way. It should provide extra assistance for the states that passed referendums to adopt Medicaid expansion. The budget should increase Medicaid funding and require reporting from the states on how Medicaid funds actually were spent.
In addition the House should pass three standalone bills by April 15. The first should be a standalone Medicare for All Bill. The second should be a tax reform bill. The third should be a DACA bill.
Finally, the House should hold a series of hearings on Voting in America with a view toward enacting a Voter Rights Act of 2020 to update the 1965 legislation, to establish standards for fairness in registration and to impose campaign finance reform.
There is an important reason for such quick action. Trump is a master of distraction. Acting quickly will keep the Democratic majority focused on Democratic goals.
18
@OldBoatMan: I think we may see a spate of government shut-downs as the Congress and Senate quarrel.
1
I doubt shutdown would happen with wise, experienced leadership. The likely outcome is that Senate Republicans will just sit on any Democratic legislation. They won't want to challenge a Democratic budget line by line, they will just pass their own budget. Impasse is always possible on a budget and continuing resolutions to avoid a shutdown are always an option.
Straight up votes on single issue -- tax reform, Medicare and DACA -- are votes many Republican senators would like to avoid.
1
Because America is not and never was intended to be democracy this proposal has real political promisng health care reform potency. America is and always has been a divided limited power constitutional republic of united states. The least democratic branch of our republic are the federal courts followed by the Senate and the President of the United States. While the House of Representatives is the most democratic branch the limits on the size of the House diminishes the power of more populous states.
9
@Blackmamba: This system is stacked against more populous states on several levels.
6
Krugman spells out what states can do but when Congress has the majority of Americans behind them, there is no excuse for lame years. Congress move ahead to craft a smart well thought out plan to improve the health of Americans and enroll more in Medicaid and Medicare or a truly universal plan. Take that well crafted plan -not to the Senate but - back to the people, the majority. Use every social and news media possible to get that message back to the people to start hounding their Senators for the improved health care plan. The most impressive lesson learned in 2018 is that local hounding drives out the dulled Republicans who cannot justify their actions to their constituents. Start scheming now new Congress, set up January mtgs with all stakeholders and get us a solid durable helpful plan. Let’s accomplish!
16
There’s a good reason why the Democrats aren’t even considering the sound course of action you described: they don’t want to risk the ire of corporate America, who would not look kindly on them taking away a major mechanism of upward wealth transfer.
Transferring wealth upward, after all, is the only thing the private health insurance system does well - quite well, actually.
8
Since the majority of Americans consider healthcare to be the top national issue, I'd like to see the NY Times devote more print to all things healthcare and a lot less of Trump. I'm bored with his distracting tantrums, I want solutions to real problems!
63
Good ideas from Krugman and commenters. Something has to happen soon.
Even with employer provided insurance patients are left with charges from Dr's and hospitals that are not covered. Medicare as secondary helps but it is running at $134 a month on top of the monthly premium from the employer plan of $180 to cover a spouse. Out of pocket expenses for a PPO can be astronomical compared to an HMO now that Aetna has become the HMO.
What a massive bundle of idiocy. Blue states are taking steps to overcome the inequities, e.g. NJ and CA, but many are left stranded. One commenter mentions that TX abandoned her but LA saved her: Odd thing for a red state to do.
Solution may be, as some have suggested, bear down on McConnell for 2020 as a major culprit for this madness. And, remember the Chief Justice of SC saved Obamacare. His wife may have beat him up to make that happen but it did happen.
8
@Harold In Texas, being pro-life is limited to being against abortion. Once born, you're on your expected to pull yourself up by your boot straps.
2
Shore up and/or improve ACA, then if the American people are ready which I think they are, offer up a private universal health care plan, something like Canada has not a socialist plan like England has.
Of course the republicans will condemn it and then use it against them in 2020, just like the democrats did with ACA in 2018.
1
@Paul
Paul, we don't have a private health care plan, we have universal single payer (Federal government).
It works well and is cost effective.
7
@Rod Sheridan
Actually, we have 13 health care plans and payers, because health insurance in Canada is run by the provinces. The federal government only provides a top-up payment because it has deeper pockets than the provinces.
And this is why Paul Krugman's suggestion is so genius. The federal government did not roll out single payer health insurance in Canad - the provinces did. The feds only got involved when we had the bad visuals of some provinces covering health care, and others not. Saskatchewan led the way, with universal hospital insurance first, followed a few years later by universal health insurance - with a mandatory per person payment, waived for the very poor.
3
@Rod Sheridan- James Eaton, Gentlemen, gentlemen, thank you for your replies, let us not haggle over details.
My understanding is that private companies are involved in Canada but Canada regulates the prices as opposed to say maybe England where it is much more socialistic ie nothing private involved.
The bottom line is that even if I am wrong anything is better than our de facto criminal health care plan of be rich, don't get sick and/or don't have a bad life event while billionaire big PHRAMA/HMO exec. get rich off the sickness of Americans.
1
Speaking of state-level action to minimize the damage done to the ACA by Trump and his pals, Utah voters decided to accept the Medicaid expansion (and voted for medical marijuana). The blue wave crashed a bit even at the base of the Wasatch Mountains.
Take that as a sign of good things to come for the rest of the nation with respect to government action on health care, folks.
5
I’m thinking maybe Mr. Krugman should have had conversations with New Jersey teachers where the Christie administration’s implementation of Chapter 78 has teachers paying an exorbitant amount of their paycheck towards healthcare. It’s the number 1 issue in contract negotiations statewide and is something that needs to be addressed on a national level.
3
@Marco Martinez
Healthcare costs money. Who should pay for it if not the patient?
3
@Ny Surgeon: the costs of health care vary across every individual's life-span. Government programs like Social Security and Medicare shift income from people's working years to non-working years. Many are gainfully employed for only one third of their expected life span.
3
@Ny SurgeonDo you not understand how health insurance works? If the fee is solely on the patient NY surgeons won't be able to pay for their own health care. There are so many rich people.
1
Universal health care, presented properly, already wins close to 60% of voters nationwide. The idea of diluting our energy to engage in 50 fights makes no sense, although it is consistent with Krugman’s past support of Clinton’s “incremental” change. It may never be acknowledged here, but one reason we are on the verge of true national, universal care, is that progressives (yes! Bernie) have stayed true to making the case. It is standard right wing strategy to throw issues back to the states - it’s easier to buy elections there than at the federal level, and if your ideas are terrible you can still maintain regional control. Look at voting rights - minus the national Voting Rights Act, gutted by the right wing supremes, we had local voting suppression interfering with the true expression of national will. Tacking to the “left” is really tacking to the true center, and that is where Democrats, a bigger minority party than the republicans, will find the independents to complete a national majority.
6
@russemiller Universal healthcare presented vaguely is what polls at 60%. Support erodes (see Vermont and Colorado) once specifics come into focus. We must be wary of overpromising and must be honest about the financing of universal healthcare (the meaning of which varies almost according to who you talk to).
2
@russemiller: State semi-autonomy perpetuates unequally protective law in the US.
@russemiller - The "right wing Supremes" tossed the VRA back to Congress to fix. Our Congress, being lazy and corrupt, did nothing. The Supreme Court ruled that pre-clearance restrictions in only certain areas was unequal treatment. I agree because voter suppression efforts are not limited to the areas that were actively engaging in those tactic in the 1960s. Voting suppression efforts ANYWHERE need to be addressed quickly. All Congress had to do was take out the named areas specified in the VRA. Couldn't/Wouldn't do it.
For the life of me (or more properly stated for the lives of Americans) I cannot understand why Republicans do not wish to have universal health care just like so many other advanced countries.
They scream about costs and loss of individual rights. But passing legislation which allows people to opt for insurance coverage only incurs costs when people choose to do it. Yes, the premium support payments are an up-front cost but are small potatoes in comparison to the costs of claims made.
More importantly, they ignore the costs of keeping the patchwork of incomplete coverage and care for those without the ACA. Disease does not stop its steady advance if there is no insurance coverage. Finding and treating high blood pressure might cost an individual (or the government funding it) $100-$200 per year. NOT treating it can easily lead to a stroke knocking the victim from employment and all too often to a nursing home existence.
Medicaid is the largest insurer in the nation and pays a disproportionate share of nursing home care after the uninsured have "spent down" their assets. That nursing home bed costs the government the same $100-$200 EACH DAY.
Keeping people healthy is the most cost effective and indeed most CONSERVATIVE approach to health care. And healthy people make for a more flexible and vibrant economy, able to adjust with changing times.
Finally, the avoidance of medical penury and unnecessary suffering is eminently just. Wake up, GOP!
16
@Douglas McNeill: Health insurance hassles are one of the principle reasons manufacturing evacuated the US.
6
@Douglas
Unfortunately, the short answer is that conservatives all want to insert profit between you and your doctor. In fact, they want to insert profit between you and everything. - education, health care, military, government - anything.
It is their faulty modus operandi.
16
Let's see why an improved Medicare for All would be better than a public option and a state-by-state approach.
The main reason is that it would be UNIVERSAL. There are huge administrative savings associated with treating everyone the same. Today there are over 1,500 different insurance plans each with their own rules and forms. Besides the obvious cost on the insurance company's side, they are monstrous compliance costs to physicians, hospitals and patients.
For the public option, you can bet the ranch that the private cos will find ways to attach the younger, healthier, and richer customers while the older, sicker, and poorer ones will flock to the public option. This will raise the cost of the private option.
For state plans, the case of VT shows you would have to exempt everybody on a federal plan like Medicare and those people who work for a multi-state corporation. Canada did it state-by-state but at the time, they did not have a complicated, chaotic system as we have today.
Also, a national plan would have the clout to approach health care on a rational scientific basis. Does new expensive drug A actually have any benefits over old cheap drug B? Is expensive radiation machine X really an improvement over standard methods and if it is in some cases, how many do we need to build?
Canada has a program like Medicare for All. Its bottom line health care statistics are better than ours. We paid $9506.20 per person for health care in 2016. In Canada, they paid $4643.70.
17
@Len Charlap: Everything else remaining the same, unemployment in the US would probably spike if US administrative overhead in health care fell to levels of other first world countries. It is a make-work system here.
1
@Len Charlap
I have worked in Canada. Canadians wait, and wait, for elective procedures. It is an entirely different culture/set of expectations. I have no problem with it, but you cannot superimpose the Canadian system on American culture and expect it to work.
3
Steve B - I also support a federal guaranteed job program as proposed by the MMT economists such as Stephanie Kelton. See
http://www.levyinstitute.org/topics/job-guarantee
http://www.e-elgar.com/shop/full-employment-abandoned?___website=uk_warehouse
https://en.wikipedia.org/wiki/Job_guarantee
http://www.thenation.com/article/your-government-owes-you-job/
Thomas Paine proposed one in 1791
NY S - We did it for older folks with great success.
Also you that only look at the patients who actually received the treatment. Since everyone is covered in the other countries, that does not effect the result, but in the US where millions have no insurance, there are many people who need surgery who never get it. This ignores these people whose wait time is infinite. Obviously if you only give a benefit to some of the people you can do it faster.
PS I am 80 and have been on Medicare for quite a while. As you say Canada is different. I have had no excessive wait times. Perhaps they should spend a little more than 45% of what we do per person.
4
It appears that the country is divided on a few issues, which shouldn't surprise anyone when you have a country of over 300MM people with different values and lifestyles. So letting the states experiment and vary would seem a quite practical approach. People can then move to the state that best fits their values. The Federal government should focus on what it is uniquely called to do -- national defense, international policy, and being an enabler of interstate commerce. NJ is a quite self-sufficient state -- they don't need to be told what do to by people outside of NJ. They don't need help from other states nor should they donate to other states.
The mistake of the ACA was taking a nice little Massachusetts experiment and mandating it across the country. The better approach would have been to let the Massachusetts experiment play out and then states could copy it as they and their citizens wanted. The key is to prevent the Federal government from mandating things. One size does not fit all -- let the states vary.
Our divided Federal legislature is a true blessing. Nothing will come from Washington DC and the states can continue their experimentation. Sounds terrific to me -- lets keep it that way!!
5
@Hopeful Libertarian It's so amusing to watch so called libertarians, basically people who don't like being told to do something and should be free to do what they want, come crashing up against other people doing the same thing.
Please, for your sake, and mine too, consider this perspective from more angles. Let go the word "mandate" and call it doing your part to make it work for you because it works for everyone. Be a libertarian if you like, but use freedom as wisely as it is a double edged sword. It cuts both ways.
Be well and healthy.
5
@Hopeful Libertarian: This silly nation forces internal migration and segregation with these petty economic competitions between states.
I wish you’d read the article. It already counters most of your points. Your comment doesn’t advance my understanding of the issues.
1
Compared to what I dared to hope for, the "blue wave" you mention was more like a blue ripple.
1
@Richard
In relation to gerrymandering, voter suppression and the cavalcade of lies, I think it was a tsunami. Also, the quality of many of the Democratic candidates was refreshing, since so many showed they could win anywhere with a true Progressive message.
It proports well for 2020.
7
@FunkyIrishman
I don't necessarily disagree. But I fear the gerrymandering, voter suppression, and cavalcade of lies will still take their toll in 2020.
1
Obama Care ended up being popular mainly because of the Medicaid expansion. It was a great idea to get more people covered by eliminating existing medical conditions, helping with the cost of premiums through government subsidies, and many other benefits but the health care still stinks. I know because my wife and I had ACA and it was awful and expensive. Maybe if someone gets a Cadillac plan they would get better care but not us.
I'm sure Social Security had its rough edges at first and over time it was improved but we don't have that luxury with the ACA. The reason it's so bad and other badly needed government programs aren't implemented is because big money owns the federal government. The most important issue at hand is to reverse Citizens United and get rid of the corrupting big money in government. Until then all Congress will be doing is spending half of its time going across the street to dial for dollars and the other half letting high paid lobbyists stuff their pockets with their money. Sorry those are just the facts. No better Obama Care, no Medicare for all, no living wage, no balanced budget amendment (yes we need to balance the budget), no nothing. Wake up people and do the right thing. Just please wake up.
5
@Rick
Medicaid expansion increased spending on the poor without looking at poverty. Many of the medicaid recipients I treat are illegals, or relatives brought here by citizens/green card holders in the name of "family reunification" and they get free medicaid, while the rest of us pay through the nose.
You cannot fix healthcare in a vacuum.
3
The Democrats need to address the cost of health care, not just access to insurance. One way they could do this is promote legislation that would require all not-for-profit community hospitals and health systems to elect their boards of directors directly from the community they serve. The boards should be broadly representative (socio-economically and demographically) of their communities. Those boards then should begin to reform those organizations-particularly with respect to how physicians and executives are compensated as well as how services are organized, delivered and priced. I believe the Democrats could get some Republican support for such a proposal-starting with Charles Grassley.
@William McLaughlin: This system was designed by the Frist family, which made its fortune asset-stripping non-profit hospitals.
Can you even fill one hand counting state legislatures with Democratic control of both houses and the Governorship? Or (you'll love this one) states with veto proof majorities in the state legislature? The A.C.A. will gain minimally over the next two years, oops, make that one year. 2020 is an election year.
The republicans only care about deficits when Democrats control government. Bush and Trump have added about $10 trillion to the debt through wars and tax cut give-aways. Republicans will never participate with Democrats on healthcare, especially McConnell, so there is no need to try. Propose Medicare buy in options. Look for a way to create subsidies for those who can't afford it and sell it to the public. Americans are owed a decent healthcare option. After years of working harder for less pay and most if not all gains in new wealth in this country being distributed to the 1%, Americans who are in the 99% are owed decent healthcare.
10
Transportation is still the elephant in the room...as any politician who prattles on about "access to coverage" will say when they know there's a massive issue that's too expensive to address honestly.
"Access to coverage" and its sister buzzphrase "access to care" are meaningless if there's no access to transportation - and the time to get back and forth from home to provider. The transportation issue may be solveable in densely populated areas, but becomes a real bear once you're outside the cities and biggest suburbs.
Not enough votes in it for anybody, though.
Nothing snaps into focus the demagoguery, vapidity, and dishonesty of the conservationism the current GOP tries to sell us as their healthcare brouhaha.
It is an obvious affront to basic human values - the types of things we like to advertise as our selling points as a Nation: compassion, equality of person and opportunity, unity, fairness, modernity, etc..
It is an obvious affront to our ability to formulate better solutions, or to at least to have the proper humility/wisdom to use other's solutions, to "problems" long ago significantly wrestled down.
It is an obvious affront to good business models and management strategy - making us look like incompetents or demagogues.
To sum up it is an obvious affront to patriotic intellectual conservatism that such dishonesty and/or incompetency is issued under its banner falsely.
And why do I - probably someone who'd be deemed a Progressive - confidently say these things?
Because the GOP efforts are antithetical to what real conservatism meant in my day: conserving our Nation's better nature, using its money most efficiently and effectively. staying grounded and formulating models and doing things that really work, and conserving our Nation's most precious resource its people.
Real conservatives honestly and competently competed in world of implementation alternatives. The GOP does not do this - their healthcare brouhaha a glaring example of how profound their antithesis is.
That should worry and bother us all!
5
"Why not, for example, introduce state-level public options — actuarially sound government plans — as alternatives to private insurance?"
Who would have thought that we would need to come up with alternative ways to limit the harm of a federal government which is dedicated to harming The People? Whether it's denying people health insurance while intentionally causing more illness with sanctioned environmental pollution, drying up farmers' markets with tariffs while raising the costs of imported goods, or assaulting our allies and making the world a more dangerous place, the Trump Administration is harming Americans.
But Professor Krugman points us in the right direction. We do not have to roll over. We can rise up in a rather Republican Party way: pursue states rights to address the abuses of the federal government.
To apply a little Ken Kesey to the Republican Party's selective obsession with states rights: states serving the interests of The People when the federal government acts to harm The People...well, that is the very definition of 'sometimes a great notion.'
5
Before considering any foreign government health plan, please take in consideration the QUALITY of health care, not just the cost and coverage.
6
@Lowcountry Joe The health outcomes are superior to ours in most of the "foreign" government health plans in addition to costing far less.
1
@RF
Outcomes can sometimes be an apples to oranges comparison. Take infant mortality. One in 8 babies is delivered early in the US. These infants aren't even counted in many countries' infant mortality statistics. For example,
"According to the way statistics are calculated in Canada, Germany and Austria, a premature baby weighing less than 500 grams is not considered a living child."*
***************
* "Infant Mortality Isn't A True Measure Of A Successful Healthcare System"
https://www.forbes.com/sites/physiciansfoundation/2016/04/12/infant-mortality-not-a-true-measure-of-a-successful-health-care-system/#6161edcd31f0
Paul, I think Democrats will misfire if they go for full blown Single Payer, mainly because some people are content with their current insurance (even if it is costing $25-$30k per family). That said, a non-profit public option (call it Medicare Buy-In) is a sure winner, both to reduce costs and as a selling point politically, putting the choice in the hands of each household. We can keep Obamacare subsidies and give recipients the option of buying into the Medicare Buy-In as well. I’d also recommend setting the premiums as an absolute dollar amount, NOT as a % which would resemble a tax and might turn off some middle income households. That’s just one reform I believe would go a long way.
3
@Joe Arena
Fine points, Joe. The fact is that most Americans are perfectly ok with their employer provided health insurance and Health Savings Accounts. Lowering unemployment is our best solution.
2
@HL
Anyone is ''content'' so long as things remain stable, but if they get sick, then the insurance they have might not cover everything they thought they were covered for. Also the costs could well exceed the insurance they might have.
Lowering the costs of health care overall, AND the costs of insurance is the best solution. That gives a massive amount of money back to the people that in turn goes back into the economy.
Win - win
1
Many people are content with their employer-provided health insurance because they don't think of the employer portion of the cost as part of their compensation. They don't see that their increases in compensation disappearing into the maw of health care costs.
Pelosi should start by reigning in the PBM entities created under Obamacare that are robbing consumers of their manufacturer rebates and driving independents out of business. Three entities control 85% of the reimbursements for Medicare and Medicaid scripts. Which in turn is actually driving up the costs of meds. Pharm spending is the biggest cost of healthcare
The Trump Administration has fast tracked over 1,600 generics through the FDA in the past two years, a much faster rate than the Obama Admin. Today script spending is going down thanks to this effort.
The Independent Market has failed, every economist can agree on that, and people have much better plans at a better cost in groups. Pelosi should take the Trump efforts to allow association plans and get people OUT of the exchanges into groups that offer plans more closely resembling ESI plans.
Krugman offers no real solutions other than partisan ramblings, and Pelosi has no idea what a PBM is even though she pushed this incredibly bad law through the House.
2
@hawk: The US Congress left no doubt what a collection of bribe-collectors it is when it established Medicare Part D while denying power to Medicare to negotiate drug prices.
4
Jared Polis, the new governor-elect of Colorado, has another interesting idea, to create a multi-state consortium to create a system that’s large enough to expand coverage and keep costs low. That would take a lot of negotiating and the devil would be in the details, but the more creative thinking on this, the better. Everyone needs to keep thinking about how best to do this on the state level.
9
@Kevin P.
An interesting idea.
At the county and town level, 2 states, Washington and Maine, have implemented insurance risk pools.
In Washington State, 26 of its 39 counties participate.
In Maine, many of the state's small towns participate in a risk pool that provides all kinds of insurance that would otherwise be beyond the reach of small towns.
A risk pool could be scaled to include a few (?) states. Care would have to be taken to have some level of homogeneity among the participant states.
Don't know how Washington State does it but here in Maine the towns are more or less the same size viz a viz population, tax revenues, etc.
It’s not the economy, stupid, but health care. Yes, this year instead of running as Tea Party lite (as in 2010), they ran as Democrats - and it worked ! Here Krugman spells out what the States can do. I think that the Dems could also propose straightforward proposals to guarantee protection of those with pre-existing conditions and massive infrastructure repairs for structures in urgent need. Either the Senate cooperates, provides reasonable alternatives, or they will pay in 2020.
9
I recommend Leader Pelosi explore Medicare for All and eliminating the cap on Social Security.
10
This is an outstanding idea and points to the importance of progressives doing the hard work of running for state and local offices rather than symbolic, grandstanding campaigns like Ralph Nader’s that handed the election to W.
4
Should be no surprise that Thomas Edison’s state is innovating in health insurance. Let’s hope Governors and other states legislatures take the time to understand what is happening in the Garden State and make some positive changes of their own. Are you listening in Kansas and Michigan with brand New Democratic governors?
1
Very interesting. So here is the real issue. As one moves from state to state the health insurance system changes. Pity the person who moves from CA or NJ to Bama, or Ole Miss. Might have a better college football team to cheer for but who wants to do that with no teeth?
5
@Paul
Even more interesting, patients are shunted from state to state by Medicaid. An illegal immigrant in one state receiving care might be shipped off to another state because he has a relative there. The burden of providing care is treated like a hot potato.
The distractions du jour are just that, never worth the time.
3
"Not since 2002 has an opposition party run so few ads attacking the occupant of the White House".
No, Paul, the opposition had replaced the news with 23 minute long attack ads on the president. It's transparent and has destroyed the credibility of the media.
4
@John The credibility of the media has been destroyed only in the eyes of Trump supporters who refuse to realize (or not care) that it is Trump who lies constantly and who has no credibility. The media often overemphasizes some aspects of politics, but it has basically done an honest job of reporting politics in this country. The media is absolutely essential to a free society.
23
@John You mean because they insisted on reporting what the president says and does?
2
I believe that healthcare, Social Security and good jobs will be the top concerns of voters in 2020 then followed by the repudiation of Trump. Baby Boomers followed by Millennials make up the largest active voter block. With Trump and his minions enactment of last year’s huge corporate tax reduction (corporate welfare) and with new individual tax cut being proposed, Trump and his minions are working to revenue starve the federal government and then propose significant changes to Social Security, Medicare, Medicaid and further slashing ACA as their austerity plan for the federal government to “live within its means,” - a cruel ploy.
People still vote with their pocketbooks and that’s especially true of Baby Boomers and Millennials.
Democrats who control statehouses like in Jersey can and should follow its lead and enact state changes to protect those buying coverage under the ACA and help reduce costs.
Nationally, Democrats need to unite and push to save Social Security, Medicare and Medicaid and push for a single payer healthcare plan all while calling out the treacherous federal revenue starvation plot of Trump and the Republicans.
Help pack Trump’s moving van in 2020!
17
@Don P.: Baby-boomers are retiring now, if they can afford to.
1
Yes, the states can do more, but this is most likely to happen in blue states, which will not help the democrats retake the senate and the presidency. The House democrats need to pass health care legislation that will show even red state voters that it will benefit them. One suggestion: Legislation mandating that medicare negotiate drug prices with the pharmaceutical industry. It won't go anywhere in the Senate, but it will make the republicans look very bad in opposing it.
7
The final and the only answer is to have Medicare For All.
Medicare A, the emergency health part, hospitals etc, should be managed at the Federal level, fully paid via federal taxes.
Medicare B should be managed by the states, would not be mandatory and there would be a premium. This premium would have a modification factor: individuals getting regular medical checkups, not smoking, exercising, drinking alcohol in moderation or not at all, would have this premium reduced by the modification factor.
5
The ACA was better than we had, but it still has fatal flaws, as we show in our upcoming book, Healing American Healthcare.
We plead with the DNC, stop talking about the ACA and Obamacare, and start talking about Medicare as a public option.
9
I don't see any plan being viable as long as the Big Pharma feeding frenzy continues unabated. Every time I hear about the introduction of a new wonder drug I cringe. Who would have thought that the miracle of modern medicine would include such a fleecing.
7
@Mor
Yes. I have lived in Norway. I miss it terribly. But I think it is you who has not lived in Norway or Europe.
I can tell you that the Norwegian people HAPPILY pay their higher taxes. It is an egalitarian society, which believes no one is better than anyone else. Janteloven. They LOVE LOVE LOVE their social system and national pension. They are happy and healthy. They don't have to worry that an illness will or loss of employment will make them homeless and lose everything. By the way, it's nearly impossible to be fired from your job in Norway.
Americans have no idea how great life is in the rest of the advanced world, nations that are progressive socialized democracies.
34
We are indeed an isolated country clueless of how the rest of the world lives. We live in fear and ignorance and just don't realize it or just don't care.
3
@Misplaced Modifier Nobody who has lived in Europe talks about “socialized democracies”. It’s a meaningless term. Who did you vote for when you lived in Norway? Labour (center-left) or Conservative (center-right)? Democratic socialists have 6% of the vote.
https://en.m.wikipedia.org/wiki/List_of_political_parties_in_Norway
In any case, clearly you haven’t been in Europe for a long time. I just came back and it’s not roses everywhere. Happiness index still shows that European countries are on top of the list but both Austria and Germany are below Israel, which is constantly threatened by terrorism and war. So “great life” is subjective. Universal healthcare (which I support, in case you wrote your response before reading my comment) helps but it’s not everything.
1
I will not vote for any politician who does support Medicare for All. I have seen too many people suffer.
7
@Zejee, gee, who are these people? Obviously not currently on Medicare. Here in rural Texas even the reddest of GOP supporters would skin you alive if you tried to take them out of Medicare, you know, that “socialist” health plan for the old. Even my well-to-do friends enjoying retirement swear by the wonders of Medicare. Listening to them extol its virtues I cannot wait to be 65!
6
Many people do not realize that Medicare, Medicaid, Social Security and most other government programs including the AAA which pays farmers not to produce are all Democratic programs. Nothing the repubs do help the working class.
2
@Zejee The people who are suffering are those who have an illness but no health plan. I don't know of anyone who is covered by Medicare who is suffering because of Medicare. Who are the suffering people you refer to?
With $12 billion in a reserve Rainy Day fund, Texas has stubbornly turned it’s back on the poor by refusing to expand Medicaid. There’s no coincidence that Republican Governor Greg Abbott’s chief of staff has direct ties to the insurance industry.
Texas Billionaires pay a disproportionately low share of the cost of state government and they’re using that wealth to keep the status quo. They hide that taxpayers still foot the bill through higher local taxes for indigent care.
Senate candidate Beto’s campaign was a breath of fresh air. Hopefully, the majority of Texans will soon see the light and the scam that’s been perpetrated on them.
In the Ohio Medicaid debate, Republican Governor John Kasich said it all.
"Now, when you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor. You better have a good answer,"
15
Kasich should have been a Democrat. Repubs have never helped the working class and the poor. Never have.
2
@Jay Trainor: At some point, further wealth accumulation is motivated only by the drive to corrupt the whole system.
1
@Rick: Kasich is a religious fundamentalist. Most of these folks view the Democratic Party as a hotbed of atheism.
1
"The A.C.A. didn’t, strictly speaking, create a national program."
Then, strictly speaking, there shouldn't have been a law at the national level, Paul.
"Instead, it set rules and provided financing for 50 state-level programs."
Again, that's a national program.
"States were encouraged to create their own health insurance marketplaces, although they had the option to use healthcare.gov, the federal site. "
Why do you need a federal law to "encourage" anything at the state level unless the national government wants to control it? That's not federalism, Paul.
4
@hm1342
Professor Krugman's description is correct, even though it apparently assumes too much of the reader. Under Medicaid the federal government sets a general framework for the design of health care coverage and devolves responsibility for its implementation to the states: that's federalism. Medicare, on the other hand doesn't have such a federal structure.
4
"The point is that while the new House majority won’t be able to do much beyond defending Obamacare, at least for now, its allies in the states can do much more, and in the process deliver on the agenda the whole party ran on this year."
It sounds like this same plan could also work for states to help mitigate climate change (see California), improve local infrastructure, and shore up public education. So why stop with health care?
If Democrats can display progress in these areas over the next two years, while Trump continues to do nothing but bloviate and mire himself in more scandals while railing against Democrats for creating gridlock with his "agenda" (i.e., lining his own pockets at the expense of the rest of us), then Democrats will be poised to claim the biggest prizes of all. They could retake the Senate and the presidency.
By showing voters political competence and grace under fire, Democrats would indicate that they should be the ones in control of the federal government. Only then can the work of healing the country at the national level finally begin in earnest.
16
Sorry, but the ACA doesn’t come close to European single payer plans in design.
After fifteen years as an American expatriate, it’s clear to me that the US could have simply modeled a health plan after the features in Europe that have proven ability. It’s not necessary to reinvent the wheel.
My American retirement health plan in California does not cover outside the state just as my Medicare coverage does not cover outside the US despite the fact that I pay all my income taxes to America and none to my adopted country.
Despite this, France allows me to enroll in its national health plan which includes dental and vision.
For Europeans it is a matter of priorities. Health care for citizens from birth is considered a top priority so it is made available to everyone!
61
@michael kittle..........of course, what really should have happened is when LBJ started Medicare in 1965 he could have included all ages from birth to death instead of just over 65.
Imagine how easy it would have been to do the right thing.
The reason he didn’t was that the cost of the American War in Vietnam made it unlikely congress would pass an omnibus bill covering all age ranges. Another reason why unnecessary wars should be avoided.
8
@Michael kittle
It is worth noting that there is no one system in the EU -- each country has their own system that they apparently find workable. The UK system is very different from the German and French system. And that is fine. Given how large the US is, it seems more practical to allow many different systems rather than trying to get 325MM people to agree on one.
3
@Hopeful Libertarian
I highly doubt most Europeans would ever hand their health care over to a large EU bureaucracy. This is what concerns Americans and why states are in best position to assess needs of their residents.
1
Why recreate state run plans when there is a federal plan ie Medicare that is functioning reasonably well and have a highly mobile population? Blame past and current legislators who do not read or understand the consequences of 3000 page policy regulations that has led to massive enrollment of Americans into horrible Medicaid health plans that no legislator would ever select for him or herself
The Medicare buyin plan would offer competition to private insurance without eliminating them and should be offered to all Americans regardless of age. Remove taxpayer funding for our legislators’ health insurance and resolution of this issue will be quickly resolved.
3
California should stop waiting for Washington and try to make this happen for ourselves. With a population of 40 million, we certainly have economies of scale.
9
When I arrived in Seattle from New York, in 2010, I had no health insurance. After registering with the local clinic, I was informed I was eligible for coverage under the ACA. I never felt more proud to be an american.
11
Republicans seem to have a problem with anything that makes life easier for the general population. Their philosophy is based on a "what doesn't kill you makes you stronger" theory, presenting the idea that hardship and struggle will improve one's life and make one "free." Of course, wealthy conservatives aren't about to apply that to themselves--and their willingness to deepen the deficit by giving tax breaks to the rich guarantees that their own descendants won't have to worry about hardship either.
16
The idea to offer an early buy-in for Medicare is effectively the famous "public option" that was so hotly debated and eventually taken off the table when the ACA was passed into law.
However, to avoid conservative backlash and the inevitable accusation of "deficit spending" that Republicans always throw at progressives, I would advise the Democrats to calculate very carefully what the actual costs of a buy-in would be, to make sure that everyone contributes an amount sufficient to ensure the long-term sustainability of the program. Otherwise, it Democrats fall to the temptation of providing a cheap, under-subsidized "socialist" medicare, you can be sure that this will be used by Republicans at the next election cycle and the entire program will eventually be scrapped.
5
“Why not, for example, introduce state-level public options — actuarially sound government plans — as alternatives to private insurance?”
Because the private health insurers who whined about their inability to compete with a public plan in 2009 leading the timid Obama to drop it like a hot potato, have even more power at the state level.
If you want anything as progressive as a public plan, you need to do it at the national level, but you’ll need a Democratic leadership with integrity - not the pro-business dinosaurs currently running the party.
10
Regarding Obamacare, the public option should be introduced by the next House. It will not pass the Senate but it will be a topic for the elections in 2020. For longer term the public must be educated that government programs like universal health insurance do NOT mean that the legislature or the government is anti capitalist. The USA will remain capitalistic just as the Scandinavian states are capitalistic, in fact we and they will remain business friendly in spite of the hate campaigns from "free marketers" (NOT) which are unleashed when any attempt to regulate capitalism are introduced. Yes, universal health care if provided by the government or subsidized by the government is by definition a socialistic program, just like the military, the fire departments, etc. Governments which have these programs are not necessarily socialistic. At least the last time I checked capitalism was alive and well in Great Britain. You can check the stock market every day.
16
Excellent idea. I’m tired of pro-business liberals like Krugman using the excuse that, because it won’t pass, there’s no point in trying.
The Democrats need to show people that they are fighting for them.
2
Thank you Paul Krugman.
Can you address these objections to the ACA and to a proposed expansion of Medicare/Medicaid that I've heard being made by it's opponents?
• The federal government will eventually pull it's subsidies to states' Medicare/Medicaid programs and leave the states holding the bag.
• Current Medicare/Medicaid payments to doctors do not cover their costs. Doctors need to balance their Medicare/Medicaid patients with enough private/privately-insured patients to remain in practice.
• An additional layer of governmental bureaucracy will degrade the current delivery of medical care.
• Reduced profits for drug and medical device companies will reduce their research and development programs.
I'm sure these objections are being addressed by people working on this issue, but discussions are not being publicized (probably a good thing - who wants to see sausage being made?)
Obama held a televised press conference during the ACA negotiations. He was speaking with reporters and representatives from all concerned corners of the medical system and a doctor asked him where all the people working in health insurance and admin will go when their jobs disappear. Obama said they could retrain and work directly with patients.
I liked that.
Then a reporter asked him to comment on a black Harvard professor being arrested as a burglar in his own home.
Guess which comment made the news?
3
@mshea29120, doctors will gladly take payments at a lower rate aka the regular Medicare rate from one payer. If they only have to submit one standard form and are paid one standard rate. It is having to hire 2 plus employees for every medical practice just to submit insurance claims. That costs $100k off the top.
I was discussing this with a top knee Orthopedic in Atlanta about two years ago and he said he would accept cash / credit card on the spot payment of $100 for an office visit that includes the x rays that they do in house. He said he would take that all day long. Considering that most of us pay $40 for a Specialist it isn’t that much more. Lots of money is paid out fighting to get the diff between those billed amount $200 -250-300 ? When everyone might agree they can live on $100 visits x 24 but they have 1/3 the back office. Maybe then your medical coders can be retrained to be X-ray techs, nurses, or PT assistants all jobs with more need and higher pay.
6
Even though California did much positive to help Obamacare be successful, the fact remains that for people stuck in the middle, above the below and beneath the upper, it remains that Obama Care created tiers that are too expensive or ones that give very minimal coverage.
A good health care program should offer good care, without a huge deductible and be affordable.
Right now, that is not the case
9
@Annie Roboff, that is why we need to do the Medicare buy -in. Last time I looked in most states where you don’t get any help a person 64 pays around $12,000 year for a Gold Plan Obamacare Plan which would be equivalent to Medicare A + B + C + D if you add up what the current average costs that Medicare is paying for these for the entire cohort is approx $8500 per year. The cohort is 65-100 +. The higher usssage is in those above 70, which is why the private Medicaid advantage plans target Suburban and affluent zipcode 65-70 users. Most folks only think the cost is $123 that comes out of their SS Check for A &B plus a sup and D.
By adding those under 65, say 50 the actuarial pool goes down. So the $8,500 cost goes down. Which is why insurers fought it.
The private pool also goes down because those 50-65 are its higher pool. Employers should be allowed to keep these folks employed instead of blatant age discrimination at 50. This will help our labor market. Company policies will come down as well.
1
The US spends more than 10,000 USD per year capita on health care while Denmark and the other EU countries in NW Europe and Canada not to forget spend around 5,000 USD, and for this half price there is free health care and hospital treatment for everybody. Also when measured in relation to gross natural product is US spending a much higher percentage.
It would be relevant for NYT to make a detailed analysis why there is these differences? And as it is rightly pointed out in the article, health care for everybody could in the longer perspective be a very important issue for the democrats if presented with correct comparison with countries where it works.
Maybe use Canada as main comparison as many In US believes that we in EU has socialism, although we have capitalism with a state that takes care of free health care and education opportunities for all.
In Denmark we have mainly public hospitals but also private. And if waiting time gets too long in the public system, the private hospitals are there too if one pay either by having an insurance or out of ones own pocket.
How can US, this wealthy country still in 2018 allow not having adequate health care and hospitals for all its citizens?
27
What if health insurance companies were forced "mandated" to sell on healthcare,gov the same types of plans they sell to federal employees at any zip code?. individual States could reemphasize the mandate on insurance companies.
This way, there will be plenty of quality plans nationwide at any zip code. Health Plans in any zip codes will be similar regardless of if an individual is a federal/ state employee, subsidy recipient or paid in full.
5
How Democrats can deliver on health care? Easy. Follow the models of Israel, Canada, and European countries. There's no need to reinvent the wheel. Their wheels work. Health care costs much less than it does in the U.S. People live longer. Oh, and those Socialists get at least a month of paid vacation and long paid maternity leave.
37
@Metrojournalist.....you sum it up. We're reinventing the wheel. The question is why.
Our media columnists/ TV pundits never compare/contrast successful postive role models abroad to debate here.
They assume it's unacceptable, so they avoid discussing it. And because it's not discussed, it stays unacceptable.
5
Do something for seniors who already qualify for Medicare:
Eliminate the $100+ monthly fee for Medicare Part B.
24
Thank you, again, for writing about our still inadequate, still too expensive and too complicated public-private health insurance system. Encouraging states to fix what Congress and President Trump could not or would not do makes sense politically, but it means we are not "one nation, indivisible" that values all our citizens equally. I am an American. I shouldn't have to live in a rich and progressive state like New Jersey or California to be able to afford the healthcare I need or move to one of those states. Neither should I have to work for a large company that pays most of the premium for my insurance or be so wealthy I can pay for my care out of pocket. Democrats in the House, not the states, need to pass a public option or single-payer bill and send it to the Senate. Senate Republicans will do nothing with it and that's the whole point. In two years, we can vote them out and get what we really need. No more patching the potholes.
36
In other advanced democracies-- also capitalist--corporate execs don't make as much money as US CEOs. These countries don't turn their elections over to big donors for funding like we do. Govts limit private money and use more public funding.
Affordable h/c for all is a norm, which their rw parties don't try to dismantle. ACA is inferior to most other h/c systems abroad that have worked well for generations. It leaves out millions, and as premium rates rise, some Americans have to drop insurance. They can't qualify for subsidies, and don't have a job with h/c benefits.
A factor in cost is that many countries actually forbid direct to consumer pharmaceutical ads. Imagine being spared the inundation of these ads which is forced on every US TV viewer day and night. Big ripple effects in medical and drug costs, and in the amount of corruption by drug makers and lawmakers.
Maybe PK could write about this someday if he feels like it.
46
@Meredith Getting your prescription filled is the health care expense you make most frequently. It doesn't mean though that prescription drug ARE the driver of the overall medical costs; all the pharmaceutical expenses are less than 15% of the total system cost, and 88% of the prescriptions are filled with generics. Even if you take away the IP rights from the pharma companies (as in the most recent ideas of Sen. Sanders) and make pricing state-controlled you'll temporarily reduce the healthcare spend by 10% or so - which will be gobbled up by the healthcare inflation in a couple of years. Doing that you permanently disable the innovation system that is responsible for more than 50% of the average lifespan increase of the last 50 years. To seriously reduce costs we need to go after the administrative expenses (yes, these 3 ladies in your doctor's office that are on the phone with the insurance company all the time), administratively end the arms race between the hospital systems (everyone wants the same super-expensive toys, and once bought they have to be paid for), reduce the defensive medicine (you most likely don't really need an MRI if you'd bruised your knee), and possibly even go after the doctors' and nurses pay - we have the largest in the world gap between their salaries and those of the ones of equally long and expensively trained people in other fields.
7
Here's a modest proposal for Democrats as they propose healthcare legislation in the new Congress.
This would pretty much fix the ACA for now and would pave the way for the future.
Introduce legislation to *Lower the age of Medicare eligibility to 55.*
Doing this would instantly and radically lower the premiums for everyone in the qualified health plan pool while also lowering the risk for insurance companies.
This would make the current ACA much more stable and solvent, by removing the highest risk, highest premium group.
Politically it would also put pressure on the Republican tax cut to provide the funds to cover this expansion.
The pressure would come from the 50+ demographic which historically has a very high rate of voting.
It would also pave the way for Medicare - For - All, as once you drop the eligibility age to 55, why not 45...?
What's not to like?
BTW - This was in the original legislation but died in committee.
305
@Jonathan from DC: Indeed, as I learned from experience, even the ACA allows insurers to charge people over 50 three times what they charge people under 50.
When I became eligible for Medicare, my health insurance expenses dropped by 300 dollars per month, and that's with a Medicare Advantage add-on.
37
@Jonathan from DC, Ted Kennedy proposed to lower The age of Medicare eligibility to 55, but, in addition to allow children under 10 into Medicare. I think adding the kids would be a political plus as well as covering a group in need.
30
We have a Medicare part A, part B and D. Now we need Medicare part E. E is for everyone. And an incremental approach lowering the age of eligibility to 55 is a good first step. Private insurance will continue as Medicare Gap policies, Medicare part D and Medicare Advantage plans. Let's do this!!
21
The fact that we spend a considerably greater percentage of our GDP on health care than comparable countries, but get roughly similar results, means that our health care system is inefficient compared with theirs. How this can be is simple to explain, since our system is based on competition and free enterprise. The health care sector of the economy competes with the rest of the economy for resources, and because its product is more essential than other products, it wins. Individual health care companies also compete with each other, but this competition is shaped by an environment that the companies join together to support and shape through lobbying, lack of transparency, and many other complex ways.
Reduction of the inefficiencies in our system would produce widespread unemployment and shrinking or failure of businesses, and could trigger a recession. Since government does not have the resources, organizations, or desire to counteract such a recession, those threatened by it will fight to keep the inefficiencies that create their jobs and businesses. For example, the system demands productivity from primary physicians, who are thereby pressured to outsource their diagnosing by ordering various tests. Test companies will protect this inefficiency with propaganda and horror stories about what happens when testing is limited.
Unwinding this will be difficult and will probably demand a certain amount of demonization of the system.
7
Taking policy advice from New Jersey should give anyone pause. The state is a fiscal wreck and they're driving out their successful producers in droves.
3
@Alan
Well, sure. Take your advice from Texas where uninsurance remains the highest in the country. Our own former governor and lamentable president W. recommended going to the ER. He did not finish the thought -- and stiff the hospital for the bill. That's the Texas idea of universal coverage.
5
Why doesn’t the Democratic congress put on the table Canadain Medicare or the European equivalent which covers everybody, is cheaper and works
Even if defeated by Senate it gets into the national debate
You Americans are the top country in the world and have the worst medical coverage of all the advanced countries. Come on get with it
105
@Ian Waddell There's a reason we don't want the Canadian or UK model. Unless you're very wealthy, and can leave the country or stay in-country and private-pay for care, you end up with unacceptably long wait times for critical diagnostic testing. Waiting months for MRI's & CT scans to evaluate potential issues like cancer is simply an unacceptable way to diagnose and treat seriously ill people. That's not medical coverage, it's Russian Roulette.
7
@Alan....those 'long wait times' are only an excuse our politicians and mega donors use to con the American voter to accept profit as the 1st priority in the U.S.
Abroad they may wait a while only for elective surgery. So what. But many commenters have told how they see a doctor quickly whenever they need to.
In dozens of other democracies with h/c for all since 20th Century, if the voters were unhappy with their systems, they'd push to make changes. Their parties would respond. But in all the generations past, there's never been a country that's ever wanted to change to US style big profit medical care.
The sad truth is not long wait times abroad---it's that over decades there have been many Americans who are dead or disabled and poverty stricken due to lack of access to care. Our politics has legitimized this.
In other countries, they would have lived, been healthy and financially decent.
Many articles about this on line, if you'd care to....
77
@Alan
No, Alan, the long wait times are only for non-emergency procedures or diagnoses. For example, a bum hip -- uncomfortable, but it won't kill you to get a new hip in 6 months rather than now.
Acute problems such as intracranial bleeding, or seriously threatening possibilities like cancer, are always treated promptly in Canada.
12
What the House needs to do is pass legislation that advances its agenda, even if--especially if--the Senate and the current resident of the White House are against it. Go for it. Put together a New New Deal that is as radical as the Original New Deal was in its day, one that specifically targets problems in our society.
Then, when 2020 rolls around, the Dems can say, "We wanted to do this, but the Republican Senate and the current resident of the White House wouldn't let us."
42
@Pdxtran The problem with the Democrats passing a health bill to campaign on in 2020 is that any bill detailed enough to be legislated and affordable will have aspects able to be demonized, without a chance for the law to be in effect for a year or more so its benefits can be felt before voters give their verdicts.
1
@Watercannon: If they keep mentioning their intentions, and if these intentions deal with real problems that average Americans are facing, the public will remember.
2
@Pdxtran What a great idea. Have the house dems pass legislation they believe in without worrying about what the senate or Trump is going to do BECAUSE they will just veto everything from the dems. They've proved that. It would be like campaigning early for 2020.
3
How about a real bipartisan effort to make the lives of middle class and lower class better with health and education programs. The corporations and wealthy already got their benefits their children will go to Ivy League schools all paid for with easy legacy admissions. Jared got into Harvard after a 2 million dollar donation by his dad, Don got over 400 million from his daddy that silver spoon crowd is just using the working class to get power. When the Trump family needs money the bank of Saudi will be open no credit approval required, Mitch MCconnell has 29 million stashed and the retired politicians will lobby for 2 million a year. They got theirs that is for sure but the rest of us will go down when the next crash hits with trillions in debt no recovery $ available. That trillion should have been spent on infrastructure creating middle class jobs and tax revenue, the rich already doing well did not need a tax cut but the gop just can't help themselves , starve the beast and cut the new deal their only goal.
11
We need to end our government of incrementalism and gradualism. The ONLY reason our government doesn't immediately implement Single Payer is because of corporate interests and lobbyists. If our representatives stopped chasing corporate money they could change this within a year. Get rid of employer-linked healthcare and remove insurance companies from the equation altogether.
And we need only look to nations like Norway, Sweden and other advanced societies for the answer regarding how we provide medical care for all. Call it socialized medicine if you want, whatever. But it works. No one in Norway worries about their medical care or emergencies because everyone pays into the system, and everyone has the same benefits regardless of employment or economic status.
I would also note that the education, training, and pay structure in Norway is VERY different. Doctors in Norway are content with their salaries. They are not greedy. Hospitals are not for profit, although a few are "private" but those are vastly less expensive than anything in America. Norway -- as all other advanced nations in the world -- regulates and provides medical care for all of its citizens. Norwegian doctors (and hospitals) take pride in their professions as a service to people. They aren't chasing money the way American health providers, insurance companies, and middle managers do. Life is a million times better for everyone in Norway.
25
@Misplaced Modifier Have you lived in Norway? Have you lived anywhere in Europe? Have you ever used any kind of single-payer system? I have and I can tell you that you don’t know what you are talking about. Doctors in Norway or anywhere in Europe are proportionately as wealthy as they are in the US. Different kinds of universal health coverage - and yes, it may come as news, but there ARE different systems - rely on high taxes on the entire population to provide the basic floor of services for everybody, with the wealthy having more access and better care. I personally think that any such system is preferable to the costly mess of the US but the ignorant demagoguery that presents the Nordic countries as a utopia to emulate is making me nauseous. And even if you are right and Norwegians are more moral than Americans, what do you want to do about it? Have the Congress pass a law that doctors have to be selfless - or else?
6
Yes. I have lived in Norway
1
Mr. Krugman, Massachusetts has had "Romneycare" for 10 years and was the model for the ACA. Rates of the uninsured are 2.5% vs. 8.8% nationally.
49
One provision of the original Affordable Care Act gave states and localities the opportunity to experiment with innovative ideas impacting everything from patient care to insurance coverage. There hasn't been much coverage or comment about what came of this idea, but PK's column today helpfully brings the concept back to the forefront of our health care challenge.
States should be the locales for health-related innovations, and why not? Given the ongoing partisan divide in Washington, you can expect nothing to emerge from Congress. But there is not restriction whatsoever on states looking at ideas that might work to reduce costs and improve patient outcomes.
Much, in fact, is underway -- mostly, however, in blue states. Republican-controlled legislatures are still in denial that health care is a high-level public concern. Sooner or later, governors and state lawmakers are going to learn to take matters into their own hands and create a health care environment that removes the anxieties so many American families about affordable health care.
Out of this bubbling up, we might see a "Medicare for All" in some states, or an expansion in others. We might see regulators taking back the ground ceded to special interests that have made American health care the most expensive in the world. Who knows what we might come up with!
New Jersey should be applauded for what it is doing. Time for other states to get moving.
11
@PaulB67....Special interests call the shots in states too---big insurance/pharma, etc. States as political units of power are smaller and weaker than the federal govt.
In states that have made progress, their accomplishments should be publicized as practical role models for the country.
We don't need 'experiments'. The federal govt is past due to fulfill the constitutional Equal Protection of the Laws, when it comes to h/c --a matter of life and death.
It cannot depend on an accident of geographical location or the whim of the current state governor, if any citizen can afford care and so live healthy or die or be disabled. These are tragedies that don't belong in any modern country.
The role models for what works are all there since 20th Century in dozens of countries. Most of our media keeps this dark. Including Krugman. Some single payer, some with insurance BUT with premiums regulated by elected govt. Democracy operates nation wide. They also finance low cost medical school---amazing?
We are generations behind the modern world. Reminds me of school racial integration in the 50s---they said, be patient, some day.
During his campaign for the nomination Bernie Sanders pushed for single payer and a $15/hr minimum wage. Hillary Clinton and the honchos in the DNC said we couldn't have it. Prof. Krugman said we couldn't have it. Y'all torpedoed Sanders' campaign. Now, with lots of pushing from ordinary people, Krugman is saying we should have state-level public options. I agree, we should--but only as a first step to the kind of single payer system you should have come out for in the first place.
12
@Martha Shelley
So Sanders proposed it and HRC was dubious and the 3,000,000 more people who voted for her thought she was probably right that he was promising what he could not deliver (I was one of them), and it was Krugman who torpedoed Sanders, and fighting that last battle and setting leftists and liberals at each other's throat is what we really need to be doing in preparation for 2020. Okay.
4
@Jeoffrey....many millions voted for Clinton not for her policies but to avoid electing Trump.
Large % of voters are ahead of the Dem Party re h/c. We can't just keep compromising when the center of politics is so warped, letting our lousy system go on for decades. Our h/c is the world's most costly, profitable and exploitive.
Great column, and near and dear to my heart as a retired RN with a husband who has Parkinson's Disease. But first I want to veer a little bit and take us back to 2009 when the Obama administration began its intense work for some kind of universal health care. With that in mind, do we remember who single-handedly rounded up enough diverse factions of House Democrats to bring a dream closer to law? It was Nancy Pelosi. We now - thank the heavens - have the House again, and we still have that passionate, savvy Nancy. Something to think about.
Mr. Krugman points out that in spite of this president and his unbending GOP Senate, we have two states, New Jersey and California, which can lead the way around obstacles and forward toward better and more affordable health care. The Democrats have also picked up governorships and more state seats. That counts for something, for sure. But there is one thing that is nagging me. Both Republican and Democratic voters had health care uppermost in their minds. And it would seem that if the GOP really cared about its constituents, it would listen and heed the needs of its people. This leads me to ask two questions of Mr. Krugman: Why do you think that Trump Inc, McConnell, and company are biting off their own noses to spite their faces? And whose interests are they looking after if not the health of the American people?
23
@Kathy Lollock They look after the profits of health insurance providers and pharmaceutical companies. These companies fund their campaigns and keep them in their seats in Washington. The provision of healthcare in the US is not decided by elected officials, it is decided by greedy CEOs.
12
While I certainly agree that pursuing statewide health care insurance coverage makes excellent sense, the soon-to-be Democratic majority in the House of Representatives needs to make sure the House passes a bill (or better yet, bill after bill after bill) that reaffirms the ACA and corrects as many of the errors in the original bill as possible (errors that were the result of the rush to approve a health care insurance bill after it became clear that the Democrats were going to lose their majority during Obama's first term). This would be similar to the House Republican majority's passage of bill after bill after bill to repeal the ACA -- only in reverse.
By taking this action, the Democrats will force the Republicans to take a position on the bill. When the Republicans indubitably vote against the bill and fail to offer any plausible alternative, it will make plain that the House Republicans who campaigned on the assertion that they support health insurance coverage for pre-existing conditions (or, for that matter, any sort of national health insurance coverage) were lying through their teeth.
10
It is impossible to practice medicine with two masters:. Patients and investors. I have no problem with multiple insurers but insurers must not be for profit. We need a robust safety net. That the Uber wealthy practice winner take all is not a sustainable social construct.
70
Health care proposals from the House should be framed to address the concerns of rural Americans. Here in Ouray County in SW Colorado, population 3,000, one traffic light, there is only one provider of health care and all that is offered are HMO plans. "Save Rural America" ain't a bad slogan for Dems.
Dems should offer to redress the failings of Obamacare in rural areas by proposing a Medicare buy-in to any area served by less than three health care insurers. This would demonstrate concern and pragmatism for those "left behind" in rural communities and create a beginning step to a gov't option and single payer.
Also, Dems should announce NOW that they will not use the threat of a gov't shutdown to advance any of their legislative desires. A gov't shut down by Dems would harm them and the country. They could post a win by simply making a statement and give up nothing.
17
@JT
Good point JT!
love your Ridgway St. Prk and the Dallas Divide - beautiful!
In California, the uninsured percentage dropped from ~17% to 7.2%, a change of 10% of 38-million people, 3.8 million people who now can get checkups, get 'that mole' or 'that lump' looked at, instead of ignoring it because of the cost. There are at least a few people who are alive now, because they had the ACA insurance instead of none.
In North Carolina, the uninsured percentage dropped, but not 10%. Using a 'best case' number for NC, let's say the uninsured rate dropped from 15.6%, to 10%, (the most it could while still being "above 10 percent") Using a 'best case' that NC, had it followed California's lead, would have a full 10% uninsured rate drop, to 5.2%, instead of to 10%. NC's 2017 population of 10.2 million, so 4.8% of 10.2 million people without insurance now, who would, in a 'California example' NC have insurance, but don't because of Republican's ACA intransigence. That's 490,000 people who might be insured (in a 'California example' NC) who now aren't insured.
How many of that 490K additional uninsured people have 'ignored that lump for a while, I'll see if it gets bigger...', or not 'gotten that mole looked at' because of the expense? Of that 490K people, if even one dies, that's on the Republican politicans who, out of partisan spite, decided to work to make the ACA fail instead of trying to make it as effective as it could be. I'd call it shameful, but Republican politicians "don't do shame"... or they would never do anything else.
21
@Jim Brokaw. I, now they pay for health inheritance and can't afford the copay. Insurance profits are up but health care outcomes are unchanged.
4
Congrats to the Democrats in New Jersey who, having kicked Kris Krispiecreme to the carpet, have struck boldly on behalf of their constituents. Here in New York we're still waiting while Gov. Cuomo rakes in tax revenues from Wall Street while telling us the Empire State can't afford its own version of universal heath care. Democrats now control 100% of everything in Albany so he's got no further excuses.
24
This is bit of optimism that is surely an antidote to Trump induced depression.
15
One objection often made to progressive state policies is that they will act as magnets, attracting migrants seeking benefits. State-level insurance mandates should work in the opposite direction, encouraging the out-migration of those who refuse to insure themselves. Let's see how that works out for states that defend the right of people to go uninsured.
11
@fbraconi
That's a really good point. Go to Arkansas if you don't want to be insured! But of course it's the healthy who will go to Arkansas, making the pool in Massachusetts that much sicker.
Relying on states to supply these health care programs is not a solution. I live in Texas. There is no state marketplace. There is no Medicaid expansion. There is no Medicaid for adults without dependent children. This is the case of many Republican controlled state governments. We need a federal solution, especially for people not earning enough to qualify for ACA subsidies. These people are not just the destitute but include people whose Adjusted Gross Income plus tax exempt interest do not meet the ACA minimum. This is common to people with real estate income that is offset by depreciation and interest deductions. They have no affordable options.
30
@David Maybe as citizens of red states like Texas continue to suffer while being able to observe huge improvements in blue state, they will come to realize that both state and federal support for the program is important. Let's be honest, short of a major change in federal government in 2020 (President and Senate), setting a good example is the most we can hope for.
34
I miss Texas with all my heart, but after my husband died last year I, with chronic illnesses and unable to afford even Obamacare, could not take care of myself. And Texas wasn't about to take care of me. Now in Louisiana - a Medicaid-expansion state - I'm getting wonderful healthcare from truly amazing doctors, to the point where I can now work part-time and yes, even pay taxes. I'm so grateful.
629
@David
Sorry to hear this but there isnt much to do, esp when TX keeps going red. Maybe TX can vote in more Democrats first. Otherwise, TX citizens reap what they sow by voting Republicans. Elections have consequences. It's a pity that the consequences have to be collective, such that even Democratic voters in Texas have to suffer for the folly of their Republican neighbors. But the more TX Republican voters suffer, maybe the more likely they are to change their minds and vote for Democrats.
20
There are still a great many who claim with great sincerity that there is no difference between the two national parties. It is on healthcare first, followed by the environment/climate change, education, and infrastructure, that Democrats can outshine and out-elect Republicans.
Trump has more than enough rope to hang himself by himself. Right, Justice Roberts?
35
@Ralph Averill
It would be more true to say there is no similarity between the two major parties. One party has fostered a whole cohort of people who do not believe in the value of expertise, the integrity of the judicial system, the validity of science, the necessity of a free press and the right of all citizens to vote. It is a grifter party that seeks to install a permanent minority government by plutocracy. The issue of health care is but one symptom of this political illness.
41
More and more, the Democratic party has the defacto plank of Single Payer & many a candidate were elected on that basis this mid term. - got a problem with that ?
There are (2) ways going forward to achieve it nationally:
1) Elect true Progressives to a super majority in the House & at least 60 Senators. This is the most direct way, & essentially if this was achieved, then there is absolutely nothing that can stop the final shift of America becoming the true Progressive country it has always been destined to be since its inception.
2) The second way is to build upon the #ACA (ObamaCares) state by state through the backdoor that is in the legislation. - essentially for any state to set up their own Single Payer health care systems. - Vermont came close.
What is MOST likely to happen is that the Democratic party will again settle for some sort of watered down medicare for all buy in after 55, and to let the states do what they want in the interim. I can only assume they will want the ''issue'' more than the solution, since they can can keep winning against republicans.
There's 2 wild cards - will an emboldened right wing Supreme Court nix any more advances (or roll back some things) & prescription drugs prices - will they be able to be negotiated in bulk or not.
The United States will eventually catch up to the rest of the modern world, but in the mean time a whole lot of people are going to hurt & perish.
It just doesn't have to be this way >
6
Our flaw---unlike other democracies--- is we let states opt out & set own rules. In PK’s phrase, “This creates a divergence in health care destinies”. “Destinies”? Like crucial life and death needs?
“Divergence”---that’s euphemism for UNunequal protection of the laws --contradicting our Constitution. Equal protection by national laws--- realized better in other democracies--means all citizens get basic respect, no matter location. Americans don't have it. Why not?
Our myth --- that letting states make their own policy protects our ‘freedom’---but from what? Big federal govt? It leaves us unprotected from corporations—bigger than our govt. Legalized biased treatment of citizens is run by local politics & dictates of big insurance/drug co election donors. PK leaves out that cause/effect. Why?
I just heard a caller to C-span say he and his wife can no longer afford their steadily rising insurance premiums ---over 2000/month. Not unusual. So starting in Jan, his wife will keep insurance, but he will not. They just can't make the payments.
We need much more than to block GOP repeal of ACA. Columnists/pundits safely ignore how big insurance calls the shots, since the media gets accused by GOP/FOX of being too ‘left wing liberal’--- per norms they’ve set up.
Income and class polarization contradicts US professsed ideals.
It's acceptable in our politics. H/C coverage in states is so "diverse", we can hardly be called a nation. Can Dems & the media frankly face it?
8
So let's see. The ACA is likely doomed for red states and likely fortified in blue states. Seems like blue state will need to start building walls for red-state caravans.
52
@Matthew as long as we can build a wall to keep Trump out too. He's been very busy sabotaging the ACA because he doesn't think that health care is a right. He, and the GOP, prefer to think of health care and health as something for the rich.
1
@hen3ry
Healthcare just for the rich would not be sustainable & they, the GOP, know it. I think their model is closer to 1) Allow people to opt-out since you can always go to the ER, right? Who cares if people are forced into bankruptcy when any losses will just be reflected in higher costs to those who pay for insurance, or the public? 2) Don’t provide insurance (and thus incur costs) for those who cannot pay. 3) Continue private insurance control with its fake, inflated costs for medical care & pharma based upon what “insurance” will pay & thus justify premium increases, all to generate increasing profits for their corporate donors. This process and the difference between billed costs & amounts actually reimbursed to providers being the real self-sustaining system generating huge profits for corporations. 4) Counter any attempts to provide more affordable & better insurance for more people with empty, vague claims of “more freedom of choice” or “job-killing changes” or “Medicare-destroying” or similar malarkey. Time to end this shell game which has been cheating America for so many years.
1
With the New Democratic House majority, I won’t get to see a repeal of the ACA. Too Bad!
I really wanted the Trump voters to get that new health plan Trump promised. You know, the one with no mandates, lower premiums, lower deductibles, and better doctor networks! I can’t see why the Republicans had such trouble designing and passing such a plan. It’s such a mystery.
Anyway, we won’t get to find out how such a great plan would work. Must be the fault of Nancy Pelosi, or Barack Obama, or maybe George Soros. There is no limit to the mendacity of Democrats that they could prevent the Republican, even when they controlled all the levels of power, from passing great healthcare for the American People. It’s a conspiracy of the Deep State, Wall Street, and climate scientists.
40
@Jazz Paw
You may need to consider putting an 'irony' or 'sarcasm' warning on a post like this. In the current climate, folks need clear labels on things. ;-)
3
@Jazz Paw
Hey, you forgot Hillary! She must have been at fault, too.
3
NJ's plan is putting lipstick on a pig, like putting duct tape on the Titanic. Let' face it, the ACA has two major flaws (may be more, but these two are the most glaring): 1. The exchanges don't work; 2. It doesn't control costs in the non-medicare markets.
Without a "public option" the exchanges vary too much from state to state and are too unstable; and they cost the consumer way too much in any case. Put in a public option and the private insurers are done; so why not go with a universal public option i.e. a variety of "medicare for all". NB: There are a lot of good ideas for several varieties of "medicare for all". Finally Paul, let's invoke morality: Some form of regulation has to come to the health care industry that converts us back to a country where we care for, instead of exploit....sick, suffering and dying Americans. The problem is getting anything true reform through a political system acutely infected with corruption. Got an Rx for reversing "Citizens United"?
8
@MTDougC Let's not forget that the "public option" was in the original version of ACA passed by the House. But it was killed by the back stabbing Joe Lieberman, who chose insurance companies and the GOP over the Democrats and the American people.
5
@Anon Yep. That's why I firmly believe that we won't get anything meaningful until after there's some sort of campaign finance reform. Krugman is one of the best, but he and the Democrats being naive if they think half-measures like the NJ plan will make any difference in the lives of everyday Americans. Two of my kids have been on the exchanges in two different states, they're terrible and there is no fixing them.
Thank you Professor Krugman! Yes, states need to take the lead in Health Care Insurance. Let us remember that ACA started in Massachusetts. Why not try something like this:
1. Enroll everyone in Medicare that covers 50-60% of claims
2. Individuals would enroll in gap insurance just like in Medicare
3. Employers would only cover their employees with a gap insurance policy. This could save them billions in costs
4 Because the cost is spread across an entire state population there should be significant cost savings in both premiums and deductibles
Are you listening Governor Newsom?
12
@Steven: Where does Medicare Part B come in? For the gap insurance you must have Part B.
You, and many others on this board, have ignored that and the fact that the premium is currently income dependent with heavy penalties for not joining when first eligible. You would have a situation where two persons, each of the same age and general heath, are paying widely different rates. As wages increase so can the Part B payment. Can you say "tax"?
Krugman makes a living on pointing out "the average" will be much better in programs that he advocates. But there are those that will be hurt by his proposals, as well as by your proposals. To you and Krugman, those folks are just collateral damage.
1
More and more, the Democratic party has the defacto plank of Single Payer & many a candidate were elected on that basis this mid term. - got a problem with that ?
There are (2) ways going forward to achieve it nationally:
1) Elect true Progressives to a super majority in the House & at least 60 Senators. This is the most direct way, & essentially if this was achieved, then there is absolutely nothing that can stop the final shift of America becoming the true Progressive country it has always been destined to be since its inception.
2) The second way is to build upon the #ACA (ObamaCares) state by state through the backdoor that is in the legislation. - essentially for any state to set up their own Single Payer health care systems. - Vermont came close.
What is MOST likely to happen is that the Democratic party will again settle for some sort of watered down medicare for all buy in after 55, and to let the states do what they want in the interim. I can only assume they will want the ''issue'' more than the solution, since they can can keep winning against republicans.
There's 2 wild cards - will an emboldened right wing Supreme Court nix any more advances (or roll back some things) & prescription drugs prices - will they be able to be negotiated in bulk or not.
The United States will eventually catch up to the rest of the modern world, but in the mean time a whole lot of people are going to hurt & perish.
It just doesn't have to be this way !
1
Funky Irishman, Dems do not control the Senate so everything you say is "pie in the sky"
2
@jonathan
I never said they did, but I predict that they will in 2 years. Count on it.
mmmmm.... pie
1
I've spoken to a few Europeans who live here. They are always shocked by how much our health care costs even with insurance and how fragmented our system is. They are shocked at how badly we are treated by our government and insurance companies and the rest of the wealth care industry. We may have some of the best research and hospitals in the world but it's of no value to us if we can't use it when we need it.
As far as I'm concerned the system that was created under Obama needs to be improved. We need continuity of care, long term relationships with our physicians, our therapists, our dentists, our optometrists, etc. It's ridiculous to be restricted based upon how much an insurance company can browbeat the physician or hospital into submission when it comes to payments. They do deserve a fair reimbursement and we should not be on the hook for the balance, deductibles, or exorbitant co-pays.
Again, if other countries can care for their citizens we certainly can do the same. If we can put men on the moon, send probes to Jupiter, we can use that ingenuity to provide health care for all, not just a select few. If our politicians can't find the courage to tell the wealth care industry that a little less profit won't kill them but their greed might kill us they are completely useless to us as representatives and fellow Americans. I'd like to see them survive the sort of treatment we get (or not) on a regular basis.
34
It's not surprising Dr. Krugman is offended by the accusation that Democrats as a party don't stand for much of anything-- other than opposition to Trump.
That it takes a crisis for Democrats to achieve majorities, which they can never sustain for more than one election cycle, apparently doesn't trouble him.
On the other hand, Republicans secretly fulfill your desires -- tax cuts for Wall Street -- and you get the soapbox.
So Nancy Pelosi and Chuck Schumer forever! And more Hillary, please! Not content with opining on the American political scene, she's now offering advice to the Europeans. What a wonderful choice this pundit made in 2016....
3
@jrd
Your post says nothing of substance in response to the column. It is merely a general anti-Democrat smear, which of course included mention of Hillary. Please educate yourself, and then direct your comments to the issue discussed in the column.
47
@Michael Banks
I don't think you read Dr. K. closely.. Did you really miss the bit about the "lazy accusation"?
That aside, the Democratic party political program -- or lack thereof -- has been a disaster for ordinary people who relied on Democrats, having no other alternative.
And yet, despite this shameful failure of governance, you're still defending the Democratic party establishment.
This immunity to reality is the route to permanent minority status. It's fine for politicians and the comfortable, but what about the rest of us? You know, persons who lack leisure and comfort and who aren't insulated from domestic policy?
Think of them for a change.
If the GOP when they held majority in the House of Representatives could vote endlessly on repealing ACA and later when they had the WH, Senate and House in their hands could not come up with anything resembling health care, the democrats even if they control only the House should pass Medicare for all. Let GOP in the Senate and Trump campaign against it all they can - they have no credibility on this issue and they will only be digging their own grave.
11
The system can only begin to heal AFTER we grant EVERY American equal income tax treatment for the full retail price of their health insurance purchases, and sell insurance across artificial zip code lines. The only feasibl eway to improve the system FOR ALL AMERICANS is via national standardization and true cutthroat competition selling one national health plan with one national provider network to one national health risk pool.
5
The democratic lead house should pass popular bill after bill and send to the senate. Run on that. Run on the senate’s unwillingness to pass a living wage, healthcare for all, zero interest for student loans and investment in infrastructure. Pass it all and stump on it and put the republicans on the defense as a do nothing party only interested in tax breaks for the wealthy. And fix the #GOP Tax SCAM. Make them defend their inaction or unwillingness to legislate for 98% of Americans.
116
@Deirdre - I agree with a strategy of passing bills to put the Republicans on the spot. However, all such bills need to be carefully thought out so as not to give the Republicans an excuse to reject them based on technical problems or defects rather than on principle.
1
The legal and logistical difficulties of moving across international borders make a national plan practical, but with no limits on migration between states, publicly financed state level plans will face a major adverse selection problem. If New Jersey were to offer a superior plan, sick people from nearby states, not to mention the entire country, would have a big reason to move to New Jersey, thereby giving the state a much less healthy pool to deal with.
3
@Jim S. The Congress indulges state eat state competition with its utter neglect of its commerce clause power to put an end to it.
1
California is a rich state and a poor state. We have many homeless simply because they can not afford a home here, even with an income. Many with homes are agriculture and ranch workers whose incomes are too low for even the plans offered under the ACA can be expensive to those living on the edge. We do have a proposal for a statewide medical insurance plan, it may seem expensive,but the opposition has a short term view of the world about them. They cannot see the long term benefits. We do have a state of antis, the State of Jefferson, 3% of the population here, like to think of themselves as rugged individualists, live in towns like Paradise, have SS and Medicare or Medicaid, vote to keep government out of their lives.
Even when their rural emergency clinics have to close from having to treat the uninsured. Getting those young healthy people in the plans will lower the premiums, but it is hard to convince them they need it until they do, then it is too late.
Problem is, young people are more likely to get physically hurt engaging in sports and other activities, but they think they are invincible, even those with families. They need a few personal examples, that is what changes minds, not arguments.
7
The missing element in discussions about health care coverage options is an honest accounting of the cost to the federal treasury of the Affordable Care Act, Medicaid expansion and specific proposals for financing Medicare expansion. Medicare beneficiaries already have bought in to hospitalization coverage (Part A) through the Medicare payroll tax and even then, the trust fund is running out of money. Buy-in cost for younger beneficiaries would be prohibitively expensive for most of them and would likely require substantial government subsidies. We can't have a responsible public debate about health care policy options unless we openly consider the financial and fiscal effects.
4
@PWR
Agree. Remove the FICA cap. Problem fixed.
SS and Medicare fixed for generations.
Tax capital gains as income, and SS and Medicare gets even more.
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@PWR
How about raising the tax rate on the top 1%, restoring the individual mandate, legalizing millions of hard working immigrants and having them pay income taxes and social security, and allowing the federal government to negotiate directly with pharmaceutical companies? Perhaps even support medical schools to train more doctors?
13
@PWR As long as health care is a for profit industry it will remain expensive as possible in order to maximize profits.
More and more, the Democratic party has the defacto plank of Single Payer & many a candidate were elected on that basis this mid term. - got a problem with that ?
There are (2) ways going forward to achieve it nationally:
1) Elect true Progressives to a super majority in the House & at least 60 Senators. This is the most direct way, & essentially if this was achieved, then there is absolutely nothing that can stop the final shift of America becoming the true Progressive country it has always been destined to be since its inception.
2) The second way is to build upon the #ACA (ObamaCares) state by state through the backdoor that is in the legislation. - essentially for any state to set up their own Single Payer health care systems. - Vermont came close.
What is MOST likely to happen is that the Democratic party will again settle for some sort of watered down medicare for all buy in after 55, and to let the states do what they want in the interim. I can only assume they will want the ''issue'' more than the solution, since they can can keep winning against republicans.
There's 2 wild cards - will an emboldened right wing Supreme Court nix any more advances (or roll back some things) & prescription drugs prices - will they be able to be negotiated in bulk or not.
The United States will eventually catch up to the rest of the modern world, but in the mean time a whole lot of people are going to hurt & perish.
It just doesn't have to be this way .
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@FunkyIrishman
From Wikipedia: "As of April 2014, Vermont had yet to craft a bill that would address the $2 billion in extra spending necessary to fund the single-payer system, and by the end of the year, the state abandoned their plan for universal health care, citing the taxes required of smaller businesses within the state."
4
@Jasper Wikipedia??? Really??? We have more than enough money to value human life: Reverse the tax cut given to the wealthy; close the carried interest tax loophole; and scrap the cap on social security taxes. Oh, and if that doesn't work, raise the deficit. The GOP has made it clear that the deficit is a non-issue when you really want something.
18
@Jasper
Aye, the money powers that be/lobbyists inflated the projections all out of proportion, because they knew that once the first state implemented it, that the dam would burst and more states would be lining up.
It is going to happen - just a matter of time.
4
There are a number of fixes to the Affordable Act that democrats much jump on immediately, which I believe Ms. Pelosi will enact. It doesn't matter if they don't get passed, the democrats need to call out the Republicans, force them into what they truly believe---if you don't have money, just die.
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The problem with health care is that states, just like you and me, are USERS of currency, not ISSUERS. So states are compelled to balance their budgets, in a way that the issuer of currency, the federal government, never has to. The national debt is now over $21 trillion and growing. It will never be paid back. Indeed, it would be disastrous for the economy if the government tried. The debt doubled from about $10 trillion when Obama took office to about $20 trillion when he left. But inflation over that period averaged a paltry 1.45%. So it's fair to ask: where's the harm in doubling the debt?
We have to stop talking about what the government can "afford." The government can pay for whatever it wants--it's the definition of a "fiat" currency that isn't tied to the gold standard or anything else. The crucial issue is whether or not federal spending causes inflation to rise to levels that robs the savings of people who were disciplined enough to defer their gratification.
So when politicians debate how much to spend on health care, pay attention to how they frame the problem. If they worry only about adding to the nation's debt, they're talking nonsense. If they instead expend their cognitive energy on trying to figure out how their policy will affect inflation, then you can rest assured that we have at least a chance of solving the problem.
7
@WDG: There seems to be wide acceptance that the government can print more money when needed.
@Jp With the many ways that we now pay our bills electronically, it wouldn't surprise me if the amount of hard chase circulating in the economy has decreased over time. So it's not so much about the Treasury "printing" money (although, of course, that still happens). Creating money is a matter of a few keystrokes on a computer. Even the term "checking account" has become something of a misnomer. How often do you actually write a check these days?
It's IMPOSSIBLE for anyone, anywhere, to buy the WRONG health plan when there's only ONE NATIONAL STANDARD HEALTH PLAN allowed to be sold by ALL insurers.
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@xzr56
No no no. We will fall into a socialist morass like the gross economic failure that is Norway.
3
@gratis Standardization is not socialism. Private for-profit insurers competing selling standardized insurance is not socialism. And since when is Norway socialist?
3
@xzr56: You've backed in a new definition of "correct" - whatever the Federal Government defines.
That'll work alright. You betcha.
If the House wants to win over Americans of both parties on health care, it needs to pass a Medicare For All bill. But it also needs to specify that "All" means ALL, including members of Congress and their staffs. I can't think of a better way to convince us of their sincerity than relinquishing their taxpayer-funded Cadillac plans.
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I’ll be listing the financially responsible individuals’ addresses as 1600 Pennsylvania Avenue, Washington, DC 20500 and
120 Constitution Ave, Washington, DC 20002, on my record with my physician and local hospital.
5
I’ll say it over and over until I die. The only answer is Medicare for all that is rationed logically and regulated heavily. We spend 18% of gdp on health care and it ain’t working. Insurance, pharma and health system execs are making obscene salaries, all the while we pay more and more and receive less and less. It’s not working and it’s immoral.
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@hb....in advanced democracies, also capitalist, corporate execs don't make as much money as they do in U.S. And affordable h/c for all is a norm, which their rw parties don't try to dismantle, as our GOP aims for with ACA. And ACA is inferior to most other h/c systems abroad that have worked well for generations.
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@hb
Amen. It's profit before people, immoral and disturbing.
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@hb
In the universe of reasonable, thinking people, which most Americans are, everybody knows this - EVERYBODY.
But just try getting it passed.
What we need to work on is making America a democracy.
31
The majority of Americans have always supported the ACA and its humanity, while simultaneously disapproving of 'Obamacare', thanks to glory of hate radio, Whites R Us Fox News and mindless 'repeal Obamacare' repetition.
In 2017, one in three Americans surveyed did not realize that Obamacare and the Affordable Care Act (ACA) were the same thing.
80% of Republicans surveyed strongly disapproved of
'Obamacare', but only 60% strongly disapproved of the 'Affordable Care Act'....even though the two items are the same thing.
The reason for the difference is part ignorance and part racism.
The ACA sounds inoffensive enough, but 'Obamacare' sounds 'black' (i.e. bad) to White Wonder Bread Republistan.
And let's remember what Greed Over People tried to replace the ACA with in 2017...healthcare insurance abandonment for 15 million Americans...weaker healthcare coverage for everybody...AND a giant tax cut for rich people...the quintessential Republican Reverse Robin Hood 'Drop Dead, America !' healthcare plan.
Even with the ACA, America's healthcare remains the world's #1 healthcare rip-off, an ongoing insult and economic crime against American humanity; Democrats should continue to work to improve it and to make it affordable.
There's only one party that gives a damn about decent public policy.
Meanwhile, the Party of Death and Stupidity somehow still manages to get votes as it offers Americans early funerals.
"Take two tax cuts and call me from the morgue !"
Nice GOPeople
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@Socrates If the ACA is so great, ALL Americans (the employed, our elected officials, the wealthy, etc) should be forced onto it in the locale they call home..
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@Socrates
There IS a mitigation for the woes of US health care. Believe it or not, there are successful systems that provide better outcomes at much lower cost the world over.
There is no need to re-invent the wheel regarding healthcare. First, declare universal healthcare a right, not a privilege, then study any one of dozens of successful systems, swallow some pride and adopt it.
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@Socrates you describe my favorite picture of the Trump era. Donald and Paul Ryan chortling in the Rose garden like Beavis and butthead. All of those GOP death panel house members who thought they had just stripped healthcare from millions of Americans, grinning and taking selfies only to be voted out of office eighteen months later. The worm turns, thankfully.
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Democrats need to set the frame, decide the talking points, and not waste their time being sidetracked by Republican nonsense, least of all by the blather coming from Trump. Trump has created a nonsense agenda of trade and immigration, and some people are pulled into these debates, debating the points while not realizing the whole agenda is flawed. Although liberals will always disagree on the specifics, we care about improving the country, really improving the country, which means an agenda encompassing human welfare, e.g., health care, inequality, corruption, rights, and the environment, but packaged to resonate with the people,
21
If Democrats want to make real changes in the American healthcare industry, they are going to have to take on the industry over basic costs, starting with Congress bargaining with the drug companies on a national level. Congress needs to tell the pharmaceuticals that Americans are going to pay what people in the rest of the advanced countries pay, or Congress is going to get real tough. The drug lords need to hear from Congress, that, when Moses received the commandments from the Lord, there was no mention of drug patents.
20
When I talk with my friends in Europe am amazed at the health care they get at affordable prices. However they all pay higher taxes for this, but when the cost of the medical care for the uninsured is factored in, that explains the higher cost here.
Many opponents are angry about the increased cost of their older insurance policies, those policies did not cover all the requirements of the ACA, or had high deductibles. They were OK for those people as long as they did not have any serious illnesses and were able to qualify to start with. Many were surprised when they were dropped for too many claims.
The GOP has always had one opposition in particular, taxes. They seem to believe everything will be OK as long as there are no taxes, as do their puppets.
The have an ally in the HMO industry whose profits are enormous. This is an industry that thrives on how much can be charged for how little you get. That is obvious in their profits and the incomes of the executives, some who are paid more than $100M a year.
Thanks to the GOP the flaws in the ACA were deliberately put there and now fixed under this House. The new House can write fixes, but Don the Dishonest will veto the, this is and opportunity to show the public just what the GOP really thinks of them.
The majority want the ACA or its equivalent, they will get it eventually, they have examples to use and force the politicians to accept public needs.
14
@David Underwood:"The GOP has always had one opposition in particular, taxes. "
"Many opponents are angry about the increased cost of their older insurance policies, those policies did not cover all the requirements of the ACA, or had high deductibles."
Have you paid any attention to the deductibles and co-insurance under Obamacare? The higher costs of that insurance is driven in part by being tied to income levels. So stop stating the cost is entirely driven by some increase in coverage.
"Thanks to the GOP the flaws in the ACA were deliberately put there and now fixed under this House."
It was the Democrats who wanted to play chicken with the states.
1
Family physician here, 29 years in the game, see a lot of Apple Health (WA state Medicaid) patients. Fortunately our practice is hospital-owned and we get paid based on charges and not collections. Otherwise we'd be out of business and there would be no one to replace us. Docs are not beating down the doors to come to rural eastern Washington.
California expanded Medicaid and now has a huge shortage of doctors who will see Medicaid (they call it Medi-Cal there) :
http://www.calhealthreport.org/2018/09/17/california-grapples-growing-physician-shortage-low-income-patients/
Why? Because Medicaid in California pays so little. You can't run a private practice on Medicaid-unless you run a mill where you see 50 or more a day and do nothing for each of them.
I agree with Krugman that expanding health insurance is a good idea, but Medicaid is not so much health insurance as it is welfare, and we know how welfare folks are treated.
Letting people buy into Medicare makes more sense. In my area it pays about 50% more than Medicaid although 40% less than good private insurance. Docs can't stay in business on Medicare alone either, but if you mix in some private patients you can make it.
The devil is in the details, professor.
83
Yes, the devil is in the details, so it would be nice to see some numbers. What is 'normal' salary of the physicians, and why they can not survive on Medicare payments. Give us absolute numbers, not a % of unknown number.
20
@vbering maybe medicine isn't a business, doc.
19
@CL
It is a business here. In the United States doctors invest substantial sums in getting trained and credentialed and are taught it is a business. In other countries medical education is rationed on the basis of merit and ability while the education is free.
23
There should be public options for both Medicare and Medicaid. Small employers and self-employed should be able to buy in. It is now well established that health care costs are higher in the United States than elsewhere because our prices are higher. Providing public options should be coupled with aggressive initiatives by states or consortiums of states to lower prices of drugs, devices, hospital care, procedures, and administrative costs, but not primary care or most consultative specialty care which is not over priced. There are many ways to lower prices. With public options and government initiatives to lower health care prices, we can make progress toward universal coverage while controlling inflation in health care costs. The Democrats can propose popular incremental legislation, and the Republicans will suffer in 2020 if the block common sense, broadly popular initiatives.
23
The House Dems should work on Medicare PLUS for all and send bill to the Senate where they will, of course, be blocked by Mitch McConnell.
In 2020 Dems should then run on a unified congressional platform of giving them back the Senate, too, and the White House, so they can finish what they started in 2018.
They should start today vilifying Mitch Mcconnell for the pain and suffering he is causing RED state citizens and link their specific opponents to McConnell (who is also on the ballot in 2020) similar to what Republicans do with Pelosi.
Dems should create a 2nd "bogey man", besides Trump, in an attempt to divide and conquer by playing off key Republicans against each other. After all, Trump will attack anyone.
654
Yes!!! Time to call out Mean Mitch with FACTS! Start right now.
131
@Paul The House of Representatives should start an inquiry on every senator and his sources of funding; just make sure the results of such serious inquiry is well known before 2020...And go deep enough to truly see where the money really comes from!
68
" .. Why not, for example, introduce state-level public options — actuarially sound government plans — as alternatives to private insurance?"
Sure. Right after y'all, for example, provide written plans and budgets. Have been waiting for BoyNee to provide them .. for 30 years.
Talk is easy. Producing written plans/budgets is hard work. Nothing more until they are delivered. We're waiting .. and waiting .. and waiting ..
5
Over 55% of Republicans and 85% of Democrats want Medicare for All. Obamacare/Trumpcare is a windfall for Healthcare Corporations and Insurers not so much for providing real health care to everyone. Over 30 million are not covered and for a large chunk of those covered it is mostly junk, since for the most popular plans they have over a $4,000 deductible. This while 61% do not have the money to pay for a $1,000 emergency.
The Democrats should put forth a Medicare for All bill in the House, even if it will lose. This will set a marker to show what the party stands for. Do they stand with Big Pharma, Insurance and Health Profiteers or with the people. If they don’t Trump is president in 2020 and the House flips back.
192
@steve
Medicare for all-->financial failure of physician practices-->not being able to see a doctor
3
@vbering
Perhaps. But why do we not see such failures in the rest of the industrialized world?
26
@vbering
1) When I cannot see a doctor, do I really care what the reason is? Whether it's shortage of doctors or scarcity of money to cover his fees through outrageously high insurance premiums, I still go without care.
2) How come other developed countries manage to cover the majority of their citizens but we can only do it for the old and for the military?
44
I think the House should hold open hearings with real experts on healthcare testifying about the affects of various proposals like a Medicare buy in, provisions to protect and guarantee coverage on preexisting conditions and other proposals. Real bills should be prepared and allow the Congressional Budget Office to report on how many Americans would benefit from these bills. Pass the Bills in the House and let all legislators establish a record on how they stand on popular healthcare bills. Then send the bills to the Senate and let Mitch McConnell do whatever to popular bills. Let all Senators, especially those running for reelection in 2020 and President Trump do their own things to kill popular bills. Let all members of Congress establish a record before the next election. For example I want my Republican Senators Blunt and Hawley and my Republican Congressional Representative Hartzler to have records on how they want to end coverage for previous conditions and/or Medicare buy ins.
131
It's not just health care. States like California have lead the way on emissions, and Governor Jerry Brown met with foreign leaders on climate change. States must fill the leadership gap left by our gridlocked Congress and Republican politicians more concerned with placating their corporate backers.
"Conservatives" love the idea of "states rights" - except when they don't.
455
@jrinsc
Sunday, in the leading newspaper in our state, there was an article about how the teachers need raises just to come up with the already low Southeast average; how our antiquated, receiptless voting machines need to replaced; how critical state agencies are being starved of funds, etc. Then, the column next it, said the governor is working diligently to...cut taxes!
Our state is known for States' Rights, but it's actually in favor of States' Wrongs.
28
@Thucydides
Don't I know it. SC is not exactly leading the way on state money for education, health care, infrastructure, etc. We're too busy cleaning up Republican ethics violations and a failed nuclear reactor project. We had an excellent gubernatorial candidate with James Smith, but we know how that turned out. States' Wrongs indeed!
13
And in red states which didn't expand Medicaid under the A.C.A., Dems should reiterate how many Federal $$ were left on the table:
https://www.npr.org/2015/05/29/410470081/texas-didn-t-expand-medicaid-advocates-say-money-is-being-left-on-the-table
like the $100 Billion$ which GOP'ers in Austin decided Texans could do without.
All the red states which just pushed back from the A.C.A. negotiating table and walked away, leaving behind money for medical care/investment - especially for financially challenged rural hospitals - should be Dem targets.
Every such GOP'er state power structure has this chink in their armor which should be exploited to the hilt by Dems - GOPers' malfeasance in this area caused neglect of medical investment, and lower care levels undoubtedly caused demise of citizens.
It's an all the more vulnerable GOP'er point for property owners in red states, most of whom pay property taxes to hospital districts - hospital districts which need bond monies to operate, and red state capitals told D.C. "we don't need your money".
Again, in Texas alone, this amounts to $100 Billion$; it's GOP'er political malpractice - gross negligence.
316
@R. Law
The only disagreement I have is on the use of the words "political malpractice" and "gross negligence." It was spite. Martin Luther King's speech on Jim Crow completely explains it, as well as Cindy Hyde-Smith campaign style today:
"... then it may be said of the Reconstruction era that the southern aristocracy took the world and gave the poor white man Jim Crow. He gave him Jim Crow. And when his wrinkled stomach cried out for the food that his empty pockets could not provide, he ate Jim Crow, a psychological bird that told him that no matter how bad off he was, at least he was a white man, better than the black man. And he ate Jim Crow. And when his undernourished children cried out for the necessities that his low wages could not provide, he showed them the Jim Crow signs on the buses and in the stores, on the streets and in the public buildings. (Yes, sir) And his children, too, learned to feed upon Jim Crow, their last outpost of psychological oblivion.”
“To meet this threat, the southern aristocracy began immediately to engineer this development of a segregated society. (Right) I want you to follow me through here because this is very important to see the roots of racism and the denial of the right to vote. Through their control of mass media, they revised the doctrine of white supremacy. They saturated the thinking of the poor white masses with it, thus clouding their minds to the real issue involved in the Populist Movement.”
https://wp.me/p2KJ3H-2sP
86
@R. Law
As a blue state resident, I applaud the rejection by Trump voting states of the ACA medicaid expansion.
Where does that "federal" money come from? It comes primarily from the higher taxation of the most successful and prosperous parts of the country, which have largely voted democratic. At least this time the taxes of Californians and New Yorkers will bre recycled back to their own states instead of being re-distributed to the uncompetitive and backward red states. www.renewingfederalism.org
13
@CH - A sentiment not helpful to the discussion (though understandable) which we ourselves have to remember to rein in, since Texas is one of the states that sends more to D.C. than is returned:
https://www.huffingtonpost.com/entry/states-federal-spending-and-taxes_us_5a2e78d3e4b04e0bc8f3b699
and since large, blue cities are the GDP drivers in most every state, even the red ones.
The point is to show the glaring mismanagement and financial/productivity hypocrisy of GOP'ers, in clinging to dogma over actual results.
Dems everywhere should keep in mind that all the states are linked together in our little endeavor; any chain - even a national one - is only as strong as its weakest link(s).
35
Voters, on the whole, Democrats and Republicans alike, agree that everyone should have healthcare coverage. We have Bernie Sanders to thank for that. When he was campaigning during the 2016 primary, he even had Republicans agree on many of the proposals he was making. Among them, healthcare is the proposal that remains one that continues to have wide support.
Obamacare, as much as it has been a godsend to many, has left out millions of Americans in the cold. Since 2015, it has been both a blessing and a burden to many how struggle to afford the premiums and cannot take full advantage of their benefits because of the cost of coinsurance, copays, and deductibles. In the event of an emergency surgery, many have thousands in deductibles they'd have to plunk down before a surgeon were to scrub for surgery, when we know that most Americans would be hard-pressed to deal with a $400 emergency.
It's time pundits and politicians aligned themselves with America on healthcare. It is more than high time to extend healthcare to all Americans, as a human right. Cut out the middlemen and about half of what we each spend will cover everyone, without exception.
My new governor is in favor of Medicare for All, though not right away. We need to push him and his supermajority to enact it now. They also need to deal with the NIMBYism that has prevented affordable housing from being built.
Human rights. It's about time
---
'Things Trump Did While You Weren’t Looking' https://wp.me/p2KJ3H-2ZW
153
Sanders, among many other places, made an appearance at Liberty University during his campaign. It was amazing to see the reception he received there. After all, it wasn't exactly friendly territory.
Three years later, this statement is one we know is incorrect:
“I would also say that as a nation, the truth is, that a nation which in many ways was created, and I’m sorry to have to say this, from way back on racist principles, that’s a fact, We have come a long way as a nation.”
We haven't. We've been going backwards...
https://www.rimaregas.com/2015/09/14/bernie-sanders-at-liberty-university-america-founded-on-racism-blacklivesmatter-on-blog42/
12
@Rima Regas. Professional studies of the so-called Medicare-for-all idea have shown this would require massive increases (some say double) in total outlays.
Furthermore, cutting out the middlemen as you say, would be followed by replacing them with bureaucrats.
4
@J. Harmon Smith
Yes, and no... We already have the framework in place. It would have to be expanded to deal with the huge increase in participants and it would seem appropriate to hire former health insurance industry employees first to fill out the expansion. Those bureaucrats, as you call them, would finally be doing positive work. Instead of finding reasons to deny needed medical procedures, they'd be coordinating and approving them.
I've seen some of these so-called studies and some are appallingly partisan and pro-industry.
Healthcare, when looked at as a human right, is worth its cost. Costs can be controlled. With universal healthcare costs will eventually come down, with a population that receives preventive care as a norm.
49