So we should do incremental change when millions of workers are terrified of losing their insurance if they lose their job?
So we should choose incremental change to let the insurers be the middle person and reject claims, deny coverage, and make us jump through hoops?
So we should have incremental change to discourage us to go to a doctor because our deductibles or co-pays are a concern?
I would like to hear Dr. Krugman's honest answers as to why we need to have employers hold the threat of losing our jobs (and hence coverage) over us, why we need administrators to make us deny coverage or hassle us, and why we need dedcutibles and co-pays to make us want to curb our own health care use. His answers would be much appreciated by this reader.
There is one predominant answer that looms, however: the forces of fear have won. Secondarily, we are a "simple" country, who can't understand change, or are too busy to try to understand why our current system needs to be much improved.
8
A very high percentage of voters like the benefits of Obamacare. As long as they're not told that it's Obamacare. Then their opinion suddenly changes. What's the matter with Kansas?
7
Senator Warren understands the realities needed to achieve major structural changes benefiting All Americans, so her 2 step just introduced is no surprise to this strong supporter of the best by far candidate for our next President.
Paul says it well, "... there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger."
Now please go to www.elizabethwarren.com and donate as I am about to do yet again. (No I am not staff)
6
On a side note I think its interesting how many times Warren's ambiguity on M4A has fooled Krugman. He first thought she was not for M4A (and wrote/tweeted about his approval of it), then thought she was (and wrote/tweeted about his disappointment in her pro M4A rhetoric) and now he's back to liking here M4A position again.
I think that says more about Warren and her shifting positions than Krugman, who has been consistent in his incrementalism.
2
To quote someone else: "Yes, we can!"
2
On Medical Care
Excessive income concerns – never my problem
Meds far out of reach for those scrapping bottom
Get freebies (I’m guessing), get minimal care
For small ills and large, their treatment is fair
For meagre income have-nots, but ‘twould be better
With boodles of income through their stormy weather,
If they had on the side a cash hoard for dipping
So when ills come a calling and seem you be slipping
The best doctors and nurses, the best of the best
Will rush to your bedside before you slip West
1
Many GenX and younger are ready for the training wheels to come off and realize the only way to make healthcare affordable for all is if basic care is covered via a single payer system.
The savings come from the overly-compensated insurance industry management and shareholders BECAUSE the funds paid-in for healthcare benefits go to health care itself.
(Personally, I wish the thousands of dollars I have paid for health care insurance which were never tapped remained within the insurance company's funds for use when medical care is necessary in the future.)
4
The reason I am for single-payer rather than the ACA, from which I benefit, is that the ACA legislation has proven too malleable and reversible under republican governance. I am for health care that sticks, like the social security system. And you have to start somewhere to get any legislation passed. If we don't ask for it, we certainly won't get universal health care. You cannot win if you do not play.
6
"incremental enough to have a good chance of being enacted, big enough to provide tangible benefits that voters don’t want taken away." Right.
Had Elizabeth Warren introduced her current two-step plan, she wouldn't have scared voters and she probably could have been the first female president.
Now she's losing steam. She might not get the nomination. Even if she did, she has already been somewhat tarnished.
Besides, Pete Buttigieg is so gifted and impressive. He may well get the nomination, and be able to beat Donald Trump, or his replacement, if that happens. Then again, I strongly support Buttigieg. If Warren is the nominee, I would wholeheartedly support her.
2
@A.G.
With Obama we got a president who could give a rousing speech, who had the greatest smile, and who completely lacked the experience and understanding to be a leader for the working class. He consequently knew only to accomplish what the status quo, Wall Street people he surrounded himself with -- Holder and Geithner -- told him to do.
Buttigieg is just as charming and just as naive about what helps the working class. He will follow in Obama's foot steps to retain the monied status quo. We need better.
5
"Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted."
And Speaker Pelosi's quote was not--as the GOP likes to spin it--to members of Congress or her caucus. It was delivered to a conference of state and local officials; the "you" was not members of Congress being denied full access to the bill's provisions--it was local officials who would understand and appreciate the benefits of the ACA once it was implemented.
I always love reading the comments of ex-pats when it comes to columns in these pages regarding health insurance. The views of people who have lived under both systems are invaluable.
It may be semantic but I feel it is important when discussing this issue to use the term health insurance not healthcare. We have relatively high quality healthcare in our country...if you can afford it. While the profit motivation may be fine in some venues for producing good outcomes healthcare is not one of them. The market based healthcare system has failed a lot of people in our society. If it had been a success we wouldn't even be having this discussion.
Years ago I asked my former primary care physician who was from Australia what he thought about a single payer system. He said that moving to that was a "no brainer" and that he almost could not keep his practice in the black financially because of the inefficiencies of having to deal with so many different insurance companies.
Republicans who are in bed with big insurance are going to keep scaring people about this. I would implore the press to stop being complicit.
Just like resistance to electric vehicles a single payer system is the future. However we get there that is likely the best outcome.
5
I believe it's the right choice to water the healthcare proposal down.
The country has followed Democrats to the moderate Republican position, with NAFTA, repeal of Glass-Steagall, Obamacare (private insurance based, copied from Mitt Romney) etc.
It will take time to get back to the traditional Democratic position, which is pro-union, pro affordable education, ...
But we need to do it, even more importantly so Republican moderates can rise in their own party again and take over. Right now there is too little space between Democrats and unhinged right. A lot of rural folks will never ever vote for a Democrat, but would prefer a moderate Republican nonetheless.
1
Warren works at familiarizing American about socialist policies. Thank you, Elisabeth.
Paul, I have been reading your columns for years, and agree with your assessment about this specific proposal.
What is distressing to me is that it should be commonly understood this is the ONLY feasible way to expect the counry to work toward universal coverage. The "Medicare for All Right Now" folks are doomed ot fail, or even cause a backlash that results in less complete coverage.
2
I believe the Democratic primaries will provide more guidance on the issue than reading the tea leaves of a few elections. In the meantime, I’m still backing both Liz and Bernie.
3
People don't like losing options. What's wrong with adding a public option and letting people keep private insurance if they (or their employer) chooses. Of course, to prevent all sick people from being on the public option and well people in cheap private polices, private insurance must take people with preexisting conditions.
@Michael
I think you explained what's wrong with adding a public option.
Howabout this:
Everyone is enrolled in Medicare for all. If you still want to buy a private insurance plan on top of that, go ahead.
I currently pay $500 a month on top of whatever my employer coughs up. Oh, and I don't have a choice, my employer only has one company.
But I know 3 things: (1) Under the current regime, our health care costs are double the international average AND (2) Private Insurance has to have a markup in order to create millions of dollars in profit for shareholders & exec bonuses AND (3) Private Insurance cos only insure healthy people under 65.
From this I can safely assume that my healthcare outlay would go down a dime but my taxes would go up a nickle - more precisely, I'd pay $0 instead of $500 a month but my taxes would go up $250 a month.
For that decrease in cost, I, and everyone I know, love &/or care about will have ASSURANCE OF INSURANCE (something that the premium we pay now does not now offer) from cradle to grave.
We all know that if we live long enough we are going on medicare. We all know people on it now. We all know that they love it.
There is no mystery here.
There is no reason for not doing this
(accept for the few thousand people who are executives or lobbyist for the industry - and that is not a reason, that is medical insurance fascism).
4
The comments section of the NYT is not the most representative place in the US to assess opinions about health care. It is skewed with supporters of Sanders and of immediate single payer insurance. Yet national polls indicate that most Americans do not favor an immediate changeover, contrary to opinions here. To me, it is incredible that all the likely resistances (we know what they'll be and from where they will come) to immediate changeover are ignored by so many including editors who omit those realities in articles about immediate single payer plans.
28
@blgreenie
Actually national polls show that when policy proposals are described to people 70% to 80% of the time they agree with the positions taken by Sanders. That's why he ran in 2016 and again in 2020 - and that's why he prefers to campaign on issues, not gimicks or emails, or personality issues. He knows that his policy positions are prefered.
I'm willing to make a concession for the Krugmanites of the world - call it Private Option.
Everyone gets enrolled in M4A - but in addition to that, if you want, you can buy your own private health insurance plan and be redundantly covered.
6
@blgreenie , which polls? name some.
2
The Democrats have the ACA and proposals to expand health care coverage. And, we can argue the merits of each proposal and any combination of alternatives. What do the GOP have? Stop Obamacare? Nice.
58
@CMK
the country was better off before Obamacare. Letting it die a natural death will be an improvement. Funny, before Obamacare, there was not a single child who did not have access to affordable care and insurance. After Obamacare defunded SCHIP, there were. It wasn't until Republicans gained control of the Senate in 2014 that SCHIP funding, as well as funding hospitals serving a high proportion of the poor was restored.
Obama gave free insurance to able bodied, childless adults at the expense of the most vulnerable.
2
@ebmem -- Please cite some sources showing that EVERY child in the country had access to CHIP (Children's Health Insurance Program) funding before Obamacare. As for your contention that Obamacare defunded CHIP, that is simply false. CHIP is still alive and well and insuring children in Washington, Oregon, and California -- those are the three states I checked, but I'm sure the same is true of others as well.
24
@ebmem -- You're also incorrect that the ACA defunding CHIP and that it was refunded by the Republicans in 2014:
"In addition, the Patient Protection and
Affordable Care Act (ACA) extended CHIP funding through federal fiscal year (FY)
2015 and required states to maintain eligibility levels through 2019."
https://nashp.org/wp-content/uploads/sites/default/files/CHIP/2012/NASHP-2012-Washington-CHIP-Fact-Sheet.pdf
15
Professor Krugman is conflicted. On the one hand he asks for a "Goldilocks" plan that is "just right" and will sail through congress and improve care. On another hand, he notes that raising the bar, as ACA did, makes people more accepting of additional positive changes.
Bernie has an unwavering drive to a universal plan that Paul rejects out of hand. While we know that approach will face huge opposition, we can't know how much could get through. At the very least we have the debate. Canada had this debate years ago and eventually the doctors came on board and Tommy Douglas pulled it through.
Note that many doctors have already foregone private practice to become employees of hospitals.
Even this election campaign is changing the dialogue as more citizens consider the options.
Big money will fight to the death. Universal health care is the opposite of everything the elites have worked for for decades. They stand to lose one of their biggest cash cows and with it a lot of political dominance. The health of Americans is of no concern to big money.
3
I’m surprised no one has talked about FDR and how he got things done in his first term. In his “First 100 Days” he issued a slew of executive orders. Then after the mid-terms, in his third year, he pushed for Social Security and Unemployment Insurance legislation.
Warren seems to be following FDR with her two-step proposal on heath care.
3
Of course what the Dems should be doing is offering a Super Secret Best Ever health care plan...only to be revealed after the election. Worked for one guy...oh, no details yet, 3 years later? Just wait til the 2020 campaign when more, even better promises of Super Secret plans will be forthcoming!
1
Speaking as a Canadian, I don't get it. What's the issue with single payer. And, having been in the health care profession, hey, a doctor is a doctor. Get a grip and bite the bullet. It really doesn't hurt.
51
@Heysus
The issue is decades of propaganda against any government program, and Republican sabotage of any well run government programs (FEMA, VA, etc.) to prove their point. If the money goes to a for-profit company, the owners can make campaign contributions.
13
@Heysus
Krugman's argument is really simply. You may not agree; but if you really don't understand that he agrees with the goal but not how to get there, then just enjoy the Canadian experience and not try to understand ours.
2
@Heysus: The US could implement a Canadian- equivalent single payer system very quickly if we were able to (a) lower provider costs, which are 10-20 times what Canadian taxpayers pay, (b) lower pharma costs, which are at least 2-3 times what Canadians pay, and (c) ration care for folks at old age (the hip implant at 90, as an example, which is more common than you think).
Since none of this will happen, we will continue on this train wreck.
Warren and Sanders want to continue feeding the virus that is the US healthcare system. Obama at least tried to arrest it's progress. Unless we arrest costs, a single payer system will not work, regardless of all the taxation that Warren and Sanders bring to bear.
2
I’m surprised no one has talked about FDR and how he got things done in his first term. In his “First 100 Days” he issued a slew of executive orders. Then after the mid-terms in his third year he pushed for his Social Security and Unemployment Insurance legislation.
Warren seems to following FDR with her two-step proposal on heath care.
2
Krugman's argument is a bit disingenuous. The only reason we're having a debate about single-payer is because years of popular pressure from below, plus Bernie Sanders's 2016 presidential run, have combined to put the issue firmly on the political agenda for the first time. The only way to get what you really need is to fight for it with a mass movement that is not in any way beholden to the dominant political parties. We may only get a half-measure at this point, but that will be more than we would have gotten without the struggle to get it all. "If there is no struggle, there is no progress" (Fredrick Douglas). And just because we get a half-deal now is no reason to abandon the struggle for the whole deal.
2
I disagree with the notion of small incremental approach. That was what the ACA was and while putting a few bandaids on here and there, it failed to solve the systemic problem.
Similarly, a "slow walk" in a happy case scenario where Warren was elected alongside a Democratic majority in Congress would go the ACA way: 2 years of debate, little results, and then the Dems losing their majority, after which the "roadmap" will be dead in the water.
The only proper way in my humble opinion is to start bold with the big ideas and let Congress feel the pressure from their constituents to do it right this time. Any deviation will serve to expose the corruptness and help oust the most corrupt politicians in the first 2 years.
3
I wonder if Dr. Krugman might tell us how much the tax exemption on employer provided health care plans costs us each year and what it would pay for in terms of health care for those who do not benefit from the exemption,
E.g., is the amount of the tax loophole, for people who are enjoying this welfare handout, sufficient to do away with all deductibles and co-pays currently in medicare? Sufficient to pay for Medicaid?
1
Anybody familiar with the history of attempts to modify our health care system realizes that there is an array of forces allied against a change of the magnitude of Medicare for All. Not all of these participants are looking solely at the bottom line. Large staff-model HMO's such as Kaiser Permanente, have no real place to go with a sudden switch to Medicare for All. Unless planning is extremely careful, KP's 12 million patients will be left out to hang in the wind, with significant difficulties in continuing their health care. What happens to the staff, patients, pensions, and the viability of this large health plan? To my mind, a robust insurance-based system is preferable as it is less disruptive. Down the line, as experience is gained with an expanded government role in health care, a single payer system could be implemented. Cost is not that big an issue. A 33-35 trillion dollar price tag for 10 years is less than the projected 40 trillion dollars we are expected to spend over that time frame with the current system.
First of all I agree that the incremental approach is the most practical and most likely to work. But unfortunately, and you can see it in this comment section, it does not offer the populist emotional impact that many people want. From what I can tell many people want the insurance, pharmaceutical companies & healthcare providers to “pay”. I can totally understand this anger. However, anger creates irrationality & extremism which may in the end cause the universal healthcare to die before even getting to the table. We must win the election FIRST then the work begins.
I haven't found information about how a public option or an eventual Medicare for All would eliminate the need for supplemental insurance, which most Medicare users purchase if they can afford it. If anyone can link me to a discussion of that I'd be grateful.
1
So a step by step approach may work better according to this article.
Here's an excerpt from the very same article.
"Kentucky and Louisiana took advantage of the Affordable Care Act to expand Medicaid, leading to steep drops in the number of uninsured residents; Mississippi hasn’t. "
How is that possible? Could it be Republicans elected in the inevitable off year wave of 2010 chose to strangle the ACA in it's crib, and because it's a needlessly complicated giveaway to a hated industry, average voters won't really defend it.
The only popular part is the Medicaid expansion which is the only thing saving Obamacare in it's current form.
Since i've moved to Canada my constant state of fear, dread, and anxiety has gone way down. I've been to the doctor numerous times and it's always been excellent.
Here's the best part if you move to a full and complete single payer system.
No more paperwork, no more hours of agonizing phone calls to hostile bureaucracies designed to defeat you to beg for coverage you paid for already. No more Go Fund Me's where you have to pray that you're photogenic enough to be bailed out.
This system is indefensible, and a two step pass has just as little a chance of passing as a full throated M4A push. That's why M4A is so important an idea, its easy to understand and sets things up in simple moral terms. The benefits are universal which eliminates means testing and the resentment that creates. It's M4A or bust for me.
1
A new president's clout is strongest at the beginning of their first term, when voters expect implementation of the promises and policies the candidate ran on. If the candidate runs on Medicare for All, the time to implement is at that beginning, not 3 years later, when who knows what has happened with Congress.
From a practical position, if Medicare for All is going to realize significant savings for the country, it needs to be fully implemented sooner rather than later to create the largest pool of the covered as soon as possible. Giving up on immediate implementation of Medicare for All before legislative discussions even start means giving up on the most cost effective way to insure everybody. Elizabeth Warren is making both a financial and moral mistake in seeking delayed implementation.
1
Although American supporters of a single payer system often refer to the Canadian model, few actually realize how that system came to be. It took decades to evolve from its beginnings in Saskatchewan as hospitalization insurance into the nationwide universal coverage system of today. Universal Healthcare is a hugely ambitious goal. It is much more realistic to achieve it in a series of steps.
3
I don't get it - so many intelligent people apparently wearing blindfolds. All the other advanced countries that have universal health care adhere to the same basic principles even if they get there in different ways. But no-one here, politician or pundit, seems to have taken the trouble to learn. I guess learning form other places' experience is just so un-American. So here it is: principle no. 1: the basic single payer system includes everyone - no opt-in or -out since that allows people to stay out and not contribute until they get sick and need it. That bankrupts the system. Principle no. 2: private insurance is OK as a supplement if people want to buy it. If insurance companies can offer something people want to buy then good luck to them. They may go away by themselves but they do not have to be banned (as long as we don't dilute principle no. 1).
Those principles have allowed the civilised world to provide better health outcomes at half the price than the US. But remember that the extra cost of US health care provides not only obscene salaries to a few fats cats, it also provides employment to an army of clerical staff administering its insane complexity. No-one has addressed that point either.
10
It boggles my mind that Warren could have gotten herself into such an avoidable conundrum. First, she proposes Medicare for all, alienating virtually every working person with employer health insurance they like. Then she proposes a trillions dollar funding scheme for the costs. And finally she back tracks to an incremental approach during her first term. How can anyone this smart think things through so poorly? She really may not have what it takes to be president. Her hate for insurance companies has fatally clouded her ability to think rationally. She has lost my support, forever.
1
Medicare For All would be cheaper and more effective for all; it's a fundamentally good idea that has been successfully road tested all over the world and even in the USA with the current Medicare age senior citizen population.
Insurance companies are useless middlemen.
It looks like the average American citizen may not have what it takes to be a basic member of civilized society.
4
@Socrates Wow! That is exactly the kind of non pragmatic thinking that could get Trump reelected. Excuse me and my moderate and uncivilized American friends as we try to patch together enough votes to end this administration. The vehicle for that is not Warren or Sanders.
I agree.
I believe that offering a "public option" will ultimately lead to nearly all Americans having access to health insurance.
Having run my own small business for over 20 years, I would have snapped up a "public option" and I believe that many small businesses will do the same.
To eliminate employer-based health insurance would basically be taking something away from people, something they may like. The GOP would be very successful at exploiting that. And, I don't think you could get such a plan thru Congress.
2
@ejr1953
The reality is(and always will be), as long as the private, for profit healthcare industry in America is allowed to maintain its control over the system, the public option proposed will really offer little benefit and in many cases it will make things worse.
The insurance industry will then be able to "cherry pick" the youngest and healthiest of society while leaving the older and sicker, whom because of increased cost to them for private coverage , will have no option but to move to the public option whose costs will be inevitably increased, which ultimately, will defeat the whole purpose of its existence. None of of these "half-hearted, piecemeal" plans will solve the issue of America having, by far, having the highest per capita healthcare costs in the industrialized world while having the poorest overall outcomes, an issue, that other countries with universal plans dealt with decades ago.
"Universal" means just that, everyone is in the system, that is the only way it will work.
1
People fear change even when the change is to their benefit. I think that Warrens two step approach makes sense. I like the fact that if challenged she thinks, evaluates and if need be makes adjustments. It is why she has my vote. I love Bernie but his rigidity will be his downfall. As for the rest of the pack they want to approach any change in baby steps. We are long past the time that we can live with baby steps.
7
With one intervention, health care, although not fixed, could become affordable. The cost of cigarette smoking and the COPD, cardiac disease, strokes, cancer and vascular disease that it causes can be calculated. About 15 years ago, based on the costs of the day, it was calculated that if a fund were to be started that would pay for all of the illness caused by cigarettes, it would add about $40 to the cost of a pack of cigarettes (and would likely be much more today). That was not considered politically feasible so the cost has been shifted onto everyone through insurance, Medicare and Medicaid.
The more sensible allocation would be for the makers of this toxic and other products toxic to health bear the cost as the condition for them to supply what should be a banned products. The benefits would be an immediate reduction in cigarette smoking and the lowering of medical costs and insurance premiums for everyone over the longer run.
This same formula should be applied to all other toxic substances that are released into the environment and are damaging to public health.
1
"Which brings me to the latest development in intra-Democratic policy disputes: Elizabeth Warren’s proposal for a two-step approach to health reform. Her idea is to start with actions — some requiring no legislation at all, others requiring only a simple Senate majority — that would greatly expand health insurance coverage. These actions would, if successful, deliver tangible benefits to millions."
I believe that Elizabeth Warren's approach is best; incremental change eventually leading to a single payer plan. It is simply the practical way to go.
3
What! How dare you suggest incrementalism!
/s
1
"The trouble with such demands, aside from the strong probability that proposing elimination of private insurance would be a liability in the general election, is that such legislation would almost certainly fail to pass even a Democratic Senate. So all or nothing would, in practice, mean nothing."
If that is true, Warren's second step would almost certainly fail to pass a Democratic Senate as well, not least because a President's strongest moments are typically before the midterms that follow their election. In other words, you're embracing defeat rather than fight for a truly universal health care program.
There is plenty of room for debate about tactics among those who believe we need to provide health care to all. I'm not sure you're among that group, though.
Inefficiency equals jobs: This seems to be the message from our right-wing friends. Whether there's a coal mine that needs to be subsidized or an insurance company that would suffer were healthcare no longer for profit, the GOP argues that preserving the past is the best path forward.
Rube Goldberg would recognize the current privately insured healthcare system that diverts money from patients to an army of well-paid bureaucrats dedicated to making sure that not a sou is wasted on actual healthcare.
I remember the scare ads funded by Koch and others as the ACA was being phased in. Since Republicans peddle faith-based economics, it was perhaps fitting that the ads portrayed Uncle Sam as Old Nick, the favorite bogeyman of religious people when trying to scare children into obedience. Clearly, such nonsense works on far too many American adults, those who feel overwhelmed by the inexorable march of reality and pine for a return to an idyllic past that never existed, a Make Eden Great Again if you will.
Thank you Kentucky voters. You got a taste of a non-GOP reality pre-Bevin, and then you got a load of the bait and switch (with a soupcon of white supremacy thrown in) offered by today's GOP. "If you give up affordable healthcare, we'll regale you with fiction about immigrants and hoodlums of color! Deal?"
Thank you Wisconsin and Louisiana. As Dubya put it, “There's an old saying ... that says, fool me once, shame on — shame on you. Fool me — you can't get fooled again.”
3
Republicans have done everything they can first to destroy Obamacare and then mis-administer it to death.
Ironically, we can all thank Trump for being transparently incompetent. More artful Republican administrations will do much more damage.
While I am glad EW has gotten out from under the M4A hairball to focus on the other, bigger things, I don't really think incrementalism can survive the inevitable long-term see-saw back to more competent Republicans. administrations.
1
First of all, Mr. Krugman was contacted by Ms. Warren personally, as was reported by Boston.com. She wanted him to help promote this approach, of gradual implementation of Medicare for All. Here it is...the Times are officially a political platform for the Democrats.
Secondly, Democratic victories in gubernatorial races does not imply a lack of support for Trump. Montanans, for instance, have elected Democrat Governors in 2004 and every election since. We have voted Republican for President in every one of those elections.
3
(2nd try)
Been there. Done that.
In 2003 I fought hard to have M4A (HR676) considered. The media, including the Times, would not even cover it. Reporters told me, "Single payer is not news." I was told there simply was not enough support for M4A, but we would take a incremental step that would lead to overwhelming political support for M4A.
But there already was support in 2003:
Here is a question from a Washington Post - ABC poll in 10/2003:
"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"
62% favored Medicare for All; 33% were opposed.
It is now 16 years later. Again we are told there is not enough support for M4A in spite of polls like the one from Hill.TV and the HarrisX polling company. It found that 70% of Americans supported M4A. (https://thehill.com/hilltv/what-americas-thinking/412545-70-percent-of-americans-support-medicare-for-all-health-care)
Again we are told we have to move slowly. Meanwhile, 200,000 people unnecessarily die every year because they cannot get the care they need. (see "amenable mortality to healthcare"). 530,000 go bankrupt because of medical expense. And we waste TRILLIONS.
"Fool me once, shame on you; fool me twice, shame on me."
6
@Len Charlap
That is what lobbyists, disinformation, scare tactics, propaganda and continued haggling about healthcare since the Truman Presidency gets you, NOTHING!
1
Been there. Done that.
In 2003 I fought hard to have M4A (HR676) considered. The media, including the Times, would not even cover it. Reporters told me, "Single payer is not news." I was told there simply was not enough support for M4A, but we would take a incremental step that would lead to overwhelming political support for M4A.
But there already was support in 2003:
Here is a question from a Washington Post - ABC poll in 10/2003:
"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"
62% favored Medicare for All; 33% were opposed.
It is now 16 years later. Again we are told there is not enough support for M4A in spite of polls like the one from Hill.TV and the HarrisX polling company. It found that 70% of Americans supported M4A. (https://thehill.com/hilltv/what-americas-thinking/412545-70-percent-of-americans-support-medicare-for-all-health-care)
Again we are told we have to move slowly. Meanwhile, 200,000 people unnecessarily die every year because they cannot get the care they need. (see "amenable mortality to healthcare"). 530,000 go bankrupt because of medical expense. And we waste TRILLIONS.
"Fool me once, shame on you; fool me twice, shame on me."
3
ACA has become acceptable to voters now that it has no personal mandate cost. But that allows for inflation in health care costs
The provision of alternatives to medicare undermines the offer that Medicare for All depends on. That undermines Paul's iterative approach as far as I can see
The clear need for health insurance in the US system does not negate the poor solutions offered by private insurance. HDHPs etc. make it risky to seek treatment.
But the creativity of US health care does need to be protected
Rob (http://www.adaptivewebframework.com/healthcarepp/en/demodwbp/awffwpwanhp.htm)
HRC first tried to fix healthcare in 1994-ish. Obama made a mess with the ACA in 2012-ish. Models for universal single payer have existed since the 1960s - Medicare... and MD's incomes soared with Medicare in the 80s.
The "conspiracy" to which we all subscribe unwittingly in most cases is about bolstering Wall Street, the banksters, the economic elite -- we have a caste/class society altho a few break thru to the top, the rest mostly aspire. Supposedly healthcare is too much of the GDP. but regulation has to be via a middleman (always the lawyers! and the banksters.) Nothing has really changed since the mid 19th C: Marx identified the problem.. but the solution seems to elude. and meantime, the human population soars... and people wonder why the climate changes.... NEXT.
Obama needs to shut up (a closet corporationist) and we need to take Warren who has defined the problem clearly seriously... and get on to discuss land use policy, resource dispersement policy (how many natural resources that are irreplaceable should be sold abroad-- esp. when derived from public lands or using infrastructure paid for by the little guy, education, energy production for the future, birth control -- stop with the boohoo about decreasing birth rate. Oh well, I don't really care do you!
3
“True, Mississippi is a very red state, which Trump won by 18 points in 2016. But Louisiana and Kentucky are or were, if anything, even redder, with Trump margins of 20 and 30 points respectively.”
Louisiana, the state with the second highest proportion of African-American citizens, is electing Democratic governors; while the state with the highest percentage of blacks, Mississippi—which is a full five points ahead of the silver medal winner—isn’t really even close to doing likewise. Kentucky and West Virginia, true “Trump country,” have far less blacks as a percentage of their population. (West Virginia can be characterized as black-free, opioid-full, and head over heels in love with Donald Trump.)
Mississippi’s relative blueness is merely a matter of demographics. Truth be told, it’s likely the number one reddest state, or very close thereto, excluding the black vote. The level of Trump support among its white population is extremely high. Let’s give white Mississippians their due.
1
Putting together a comprehensive health care coverage is not all that difficult.
1. Put Medicare For All in place
2. Medicare A, the emergency type of care, to be run by the Federal government. If I have a heart attack Medicare A kicks in, no questions asked because Medicare A will be paid for via taxes.
3. Now that I have had a heart attack any following treatment to be paid by Medicare B. Medicare B to be run by the states or by the federal government, no questions asked. Paid for via taxes.
4. What about preventive care? Doctors visits, mamograms, annual physicals? Here is where the individual will buy insurance. Now Medicare C will come into play. There will be premiums. Medicare C will be mandatory. Premiums will have a modification factor. If I do not smoke, I work out regularly at the fitness center, I do not smoke, my premiums will be modified to a lower level. Medicare C to be managed by the states.
5. Insurance companies can play a role but the individual citizen will never have to deal with them. All at the backend.
Let us just do it.
If the Red ( Redneck) states refuse then the blue and purple states can join forces to put Medicare For All in place
2
Rural votes don't matter.
Of course, that is what Buttigieg has been proposing all along...
I was wondering when the NY Times would start to cave in and advocate for the "moderate" Democrats. Yes let's keep compromising until we get back to the good ol' Obama-Clinton centrists. Where did that get us exactly?
I didn't think Mr. Krugman would be part of this sad acquiescence but I guess I'm not surprised; perhaps disappointed would probably be a better adjective.
3
I'm a Bernie supporter and a huge advocate for a single-payer/M4A system. The challenge is getting there. Many activists and advocates have what I call a Thanos complex or an Infinity Snap mentality to movement politics. This is dangerous to the political endgame (pun intended). https://madsociologistblog.com/2019/08/24/the-infinity-snap-fallacy-of-movement-politics/
You give Warren full credit for what Biden has proposed all along.
2
For a deep dive--10,000 words, all golden--see Charles Gaba /Brainwrap on DailyKos today:
-An-Inconvenient-Truth-Elizabeth-Warren-finally-admits-it-ll-take-at-least-TWO-bills-to-achieve-M4A
I don't know why David Leonhardt's column is not showing up on my front page, but he echoes Charles Gaga's superb work.
https://www.nytimes.com/2019/11/19/opinion/elizabeth-warren-medicare-for-all.html?rref=collection%2Fbyline%2Fdavid-leonhardt&action=click&contentCollection=undefined®ion=stream&module=stream_unit&version=latest&contentPlacement=1&pgtype=collection
Americans will not tolerate having their employer health insurance ripped out from under them. It's that simple. They hated the ACA even though most weren't affected by it. Think how they would feel about single payer national health insurance. It's a guaranteed general election loser for any candidate who promotes it.
I've been a single payer advocate for decades, but after the uproar over the ACA I've come to realize single payer is not feasible in one fell swoop in this country. It needs to evolve. A public option would be a good start.
1
Here’s when a few countries started HC for all—See True Cost Blog for a complete list:
Norway 1912 Single Payer
New Zealand 1938 Two Tier
UK 1948 Single Payer
Canada 1966 Single Payer
Netherlands 1966 Two-Tier
Finland 1972 Single Payer
France 1974 Two-Tier
Australia 1975 Two Tier
Switzerland 1994 Insurance Mandate
As an award winning economist with expertise in inequality and international economics, could Mr. Krugman please explain how these countries did it?
3
@Meredith I'd like to add:
Germany - Health Insurance Bill of 1883.
Passed by stubbornly conservative chancellor Bismarck, after growing public demand, fueled by Social Democrats, didn't leave him another chance. But 136 years later, US "experts", like Prof No here, still pretend huge change can't be done? Ridiculous.
1
This is just common sense.
I like Bernie a lot but one of his supporters should do an easy to read opinion piece to explain why his plan is more likely to be successful electorally and practically than Warren's.
And do it soon.
2
Sigh, another dishonest low quality US political debate about a vitally important issue.
My premise - no country can afford CadillaCare for all, so they all ration - the different systems are simply different methods of rationing. In the US today we ration by cost.
And this nonsense of eliminating "private insurance". It seems the candidates don't know anything about the different "single payer" systems. Medicare Canada covers around 70%of the cost, most Canadiens carry supplemental private insurance to pay for the rest - just like American Medicare. In the UK the NHS covers about 80% but 20% is private and prescription drugs aren't "free" there's a co-pay - it's something like $15. Germany has both public and private. Even Sweden has private care although rare.
What Sanders and Warren are proposing is a new untried "single payer" model which is radically different. "Any doctor, any hospital, whenever you want" isn't possible and we all know it. Some cancer patients will get into Sloan Kettering but some will end up at the Mississippi Roadside Cancer Clinic.
The data exists, we know what works, why not cobble together a sensible "plan" that would work for all of us and not bankrupt our country?
I also want a new pony, so far I'm 0 for 2.
3
Medicare-for-All need not mean the elimination of private insurance. If it is to be like the current Medicare, there would still be "Medigap" and "Medicare Advantage" policies for those who prefer them.
3
I'm an old guy (70) who fell in love with a German woman and moved to Germany 7 years ago. I'm lucky to be here. In that time I've been hospitalized 4 times with 3 operations. The care was great, and I'm fine now. In the US even with insurance it would have been expensive. Without insurance I would have been bankrupted. In Germany I pay the equivalent of $200 for the insurance that everyone is required to have. Copays for most medications are $6 for 100 pills, and my out of pocket contribution to my hospitalizations was capped at $275 per year. After a hip replacement, I was sent to rehab at a nice clinic in the Black Forest that offered me a private room with a balcony. All this at no cost. University tuition here is free as well. If you watch Fox News, you might think that Germany is awash in debt. The truth is that they've balanced the federal budget 3 years in a row. I love the US, and my wife and I would like to have the option someday to return there to live. In many ways America is more free than any other country in the world. No one can really be free, though, if he is constantly plagued with worry about how he would pay for care in case of a health emergency. The rest of the Western world has figured this out. They've achieved as good or better care for a fraction of what we're paying. I don't understand why we're being so timid and what we're waiting for.
7
@Levi One correction to my comment. It's $200 a month for health insurance.
4
Perhaps Americans should all be required to go back sit down and watch Michael Moore's "who do we invade next" a tongue in cheek invasion of numerous countries, mostly, though not all, European. The intent being to "steal" the best ideas from these countries for use in the U.S. It covers everything from school lunches, vacation policy, drug laws, health care, education, workers having seats on corporate boards, prison reform, and the financial crisis of 2008.
The big point Americans should see is the "cost" of these programs. Yes Europeans pay more taxes, yet they also don't pay what we pay for education, health care, even school lunches. Which when you factor this in puts us way over the top comparing what we pay to what we get. We pay a lot more for much less. If only people could see the whole picture. That it is unaffordable is the lie that Republicans push upon us.
4
Elizabeth Warren is a very reasoning person. When she saw the difficulty that a straight jump to eliminating all private health insurance was going to cause, and watched her own poll popularity diminish she appropriately proposed another pathway. The Bernie Bots are just that, and fail to reason. The Trumpkins are in total thrall and have abandoned reason. It is up to the remaining rational (hopefully majority) people in this country to elect someone as rational as Elizabeth Warren.
2
The characterization of the ACA as a panacea in this column is baffling. While it helped insurance become more accessible to the uninsured, it did absolutely nothing to address the real problem in the health care system which is out of control costs. Since the ACA, my premiums and deductibles on my employer sponsored plans have increased while the coverage is virtually non-existent. Any action that the next President and Congress take to address this, must start with cost reduction.
3
Paul Krugman extols the value of incrementalism for getting major accomplishments done. He forgets the value of shifting the Overton window in getting these incrementalist changes accomplished. Bernie fighting for M4A and describing it accurately as just being a version of healthcare that already exists in every major country and indeed exists in this country for those above 65 is what has shifted the conversation around this topic so quickly in the last 3 years. Its Bernie's efforts that now make the public option (something that incrementalism could not accomplish back in 2008) as a somewhat "middle ground" compromise. Bernie creates the space for these incrementalists to offer their more "reasonable" plans.
Now think how much more incrementalism we could accomplish if Bernie was president. If you like incrementalism then Bernie's shifting of the Overton window as president is something you should be looking forward to.
1
"What she (Pelosi) meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life."
What's $695.00 to $2085.00 to Pelosi? Ok, I didn't use the web site that claimed it was a $100.00. What's a $100.00 to Pelosi. the best quote I had under A.C.A was $487.00 a month. That's $5844.00 a year. If Pelosi can't understand that's to much for some people why is she calling herself a Democrat?
2
Many of those idealistically supporting single payer forget that the health care industry as it exists today employs millions. After all it is 17% of the economy. How many of those millions would support every progressive idea out there, if they could do so without fear of losing their jobs? And how many people would be reluctant to vote for a candidate whose policies, if enacted, would upend their lives because their job at Blue Cross, or an insurance agency, would be eliminated by Medicare for All? Stop and think, people. Sometimes the incremental approach is the only one that will get enough votes.
2
@Northsider,
I agree.
A lot of comments here seem to want to cast those working in the healthcare industry as evil and should be punished with unemployment or worse.
In reality those working in the healthcare industry are just ordinary people--many of them are not rich but rather working or middle-class-- trying to make a living, no different than any of us.
Taking joy at legislating the livelihood, of a large number of people, out existence is not a good strategy.
3
@Louis Afaics, nobody is talking about kicking a large number of people out of their jobs. They will still be needed for providing healthcare, after all. And even many administrative staffers working for private insurers now will only have to apply for jobs at expanded Medicare. High income managers will be set free and look for new opportunities, though. And the profits of pharma corps and hospital chains will be reduced. That's nothing to be afraid of, just a market correction.
2
The problem with Bernie Sanders and Elizabeth Warren's original plan is that it basically relies on a "trust me" mentality that requires people to take a leap of faith that what they will end up will be better than what they have now.
Contrary to what a lot of people on here seem to think, skepticism about single-payer is not purely driven by greed and selfishness but in some cases by bad experiences with existing single-payer programs: e.g. a veteran having issues with the VA or a Medicaid recipient having difficulties finding providers that will accept Medicaid.
While this does not mean programs like the VA or Medicaid are inherently bad--the contrary they do work reasonably well for many of their beneficiaries--it is important to acknowledge their shortcomings and try to learn from them and develop a better policy if single-payer is the goal.
With respect to those with employer based coverage some people genuinely do like the coverage. However, others don't like it but are afraid, rightly or wrongly, what they will end up with under a single payer system will be worse.
Incrementalism is the only realistic way to get there.
Warren and Sanders think that the issue is mostly about big business buying influence in government. They ignore the experiences of poor functioning bureaucracies upon which people are forced to rely. Everyone who has ever applied for Social Security or renewed a drivers license has experienced the problem. It makes their slam dunk assertions about totally changing the system into an unbelievable one.
1
Most health insurance companies, and even hospitals, also fall squarely in the category of poorly performing bureaucracy even when they are privately owned and managed.
3
Has anyone out there ever had to navigate the bureaucracy of Medicaid eligibility, either for yourself or on someone else's behalf?
It can be very intimidating and complex. If you ever have to show up in-person to one of their offices, it is a lot like waiting at the DMV--you wait in line for an indeterminate amount of time before you can see someone.
If incremental reform provides good coverage, pretty soon people will be asking, "why am I stuck with this expensive private coverage?" Ultimately, single payer will prove to be far away more cost-effective. Use the carrot, not the stick.
2
The reason why Medicare works as well as it does now is that almost everyone on it paid taxes to support it for many years before they claimed benefits. Also, there are numerous things, such as dental care, that Medicare doesn't cover, so to use it properly seniors need to buy Medicare supplemental insurance or a Medicare Advantage plan.
I am 100% on board with the idea that the current system needs to change. My concern about Medicare for All is not a tax increase, which would be offset by out of pocket savings, but a bloated unworkable government bureaucracy once everyone in the U.S. is on the system. It's not clear how much freedom we would have to choose our providers under such a system and the size of the organization might mean slower turnarounds, which could have serious health consequences. I think that any candidate for the Presidency should be offering voters more options, not fewer. As an example, the Canadian system covers everyone, but sometimes the waiting period is long or quality of care is wanting -- most Canadians have no choice but to accept it, as it's a monopoly. Those with money come over the border to the U.S. to get better care than the one-size-fits-all system affords.
2
@tamar44
The Canadian system is"so poor" that the average Canadian lifespan is almost THREE YEARS longer than his/hers American counterpart.
2
With Mitch McConnell as Republican majority leader, would even Sen. Warren's proposal pass? The ACA passed with a sixty vote Democratic majority.
If they can get 50 dems in the Senate they can get many reforms passed through budget reconciliation. If the Republicans keep the Senate it will be another 4 years of absolutely nothing.
We will sadly just have to watch the working class republicans get less and less affordable health care until they effectively have none, unless they are over 65. If they live that long. Thing is, their hatred of anything or anyone in the "liberal" camp is greater than caring about their families health, so as long as the rhetoric raging against anyone "not them" continues, they will vote against their own interests. Truly "deplorable's". Not because they are working class or religious or like hunting, all mainstays of American life. But wanting to ram you religious and cultural rules into others lives IS deplorable. Refusing to do the slightest thing to help the planet or the undeserved is deplorable. Supporting The Autocrat and his Billionaire free riders is deplorable.
2
A way to incrementally introduce M4A over 3-4 years is to have a Medicare for ALL lottery based on birthdays. To introduce M4A over one year, you would pick a birthday every day for 365 days, over two years pick a new birthday every other day, over 3 years pick a new birthday every 3rd day and so on. This would allow time for private insurance to adjust over time and be phased out entirely, and for Medicare to add new enrolless slowly. It could be adjusted to do it slower or faster by lengthening or shortening the time interval.
For example, the first number drawn in the lottery is 254 corresponding to September 14th, and therefore all Sept. 14 birthdays are automatically enrolled in Medicare for All - complete coverage womb to grave, no premiums, no copays, no deductibles, no being dropped from the program because you get too sick to work, or get serious illness, such as cancer.
Next lottery selection number would be 3 days later (for 3 year phase in) as E. Warren wants to do. Next pick April 24th, so now all Sept 14 and Apr 24 birthdays are covered by Medicare for All.
Some people will nay say this and pick it apart, but every system can be picked apart. The one that needs to get picked apart and thrown away is our current system as it is too expensive, too discriminatory, too unfair, and a defective system, leaving millions uninsured or under insured.
2
Dear Mr. Krugman:
New York Times very recently has reported that Ms Warren sought for your favorable comments about Medical-for-All that she so proudly endorsed. I have read your previous opinion that you were not a fan of Medical-for-All for a practical and realistic reason. Are you now compromised and caved in? Does every candidate need to be honesty and think through carefully before she/he endorsed any policy? It took Obama administrative one term to implement Affordable Care Act. The first step of Warren's administrative is not implement anything for three years. Can anyone guarantee that she will be re-elect second term?
If anything, Democratic victories in Virginia, Louisiana and Kentucky are indicators that more Democrats are going to the poles. Democrats are getting out their vote, and that's great.
But a national election is another matter. Republicans will not vote for ANY Democratic candidate. Maybe a few could pull the lever for Biden, but Trump has succeeded in giving them a reason not to vote for Biden, and he will harp on that from now until next November and beyond. And FOX Noise will be right by his side every step of the way, which makes unseating Trump not only very daunting, but also unlikely.
Getting out the vote and appealing to the limited pool of independent voters is nonetheless the Democrats' best chance. But so is the person who actually becomes the Democratic nominee. Obama captured the American imagination. Unfortunately, the current crop of Democratic candidates hasn't managed to do that.
1
It doesn't make sense to compare the outcomes of this state elections to what voters want in the presidential primary. These states didn't have robust year long primaries televised internationally with a multitude of candidates, I really don't see the comparison. Most polls however show the public is demanding medicare for all.
As someone in poor health, I want to offer my appreciation for the ACA. I have end-stage renal disease, heart failure, and cancer. I use Medicare as my primary insurance and an ACA policy as secondary insurance. The ACA policy has expensive premiums and a high deductible, but the out-of pocket maximum protects someone like me with huge medical bills. I understand that many people would prefer lower deductibles and premiums, but for people with really high medical bills the ACA policies provide vital protection. I bought my own insurance before the ACA and was charged a huge premium because of my health. I am definitely better off now.
4
Who's to say that "Warren's approach" isn't what all the other candidates except Sanders have in mind?
1
Obama is right; given our history of government skepticism, polarization, and fear of change, incrementalism is the only thing that will work.
This insight, while perhaps cowardly to some, is becoming more and more accurate as our news sources become more stratified, and one political party and its wealthy-backed media, feels no shame in peddling outright falsehoods and scare tactics. Remember the death panels?
Sure, anybody who has given even a cursory glance at how Americans are getting drained by powerful healthcare interests and their lackeys in congress understands we need a drastic makeover.
Great in theory, almost impossible in practice. Obamacare was a relatively conservative partial add-on solution to our dysfunctional system. Almost ten years later, it has only gotten marginally more popular, having survived a gauntlet of sabotage, misinformation, lies, inaction.
But finally, it has gained enough solid support that, at the very least, a majority can see building on it. If not a radical expansion, at least to "fix" it.
Krugman is right. That is where we must go from here.
1
Mr Krugman's comments are interesting and seem likely to be accurate. We should remember that Obama care (more accurately Pelosi care) was unpopular among part of the electorate in the last presidential election. For many it was very expensive. It became more popular as Trump and the Republicans tried to undermine important popular provisions like coverage for preexisting conditions. Then they tried to remove it entirely. Obama/ Pelosi care is not an efficient or effective starting point for better health care except that it, as Mr. Krugman, suggests gave many a glimpse of affordable, humane health care.
Here is a thought. Make Medicare available to everyone at premiums less or about the same as market insurance. Many small employers would jump at that and many who believe in Single Payer system like I will happily subscribe to it. I know some CEO of big companies who also support Single Payer system will opt for the Medicare.
3
So once everyone gets into Medicare, the employers will return all costs previously associated with healthcare 'benefits' back to the employees in the form of compensation, right? Right?
1
@Buyback
No those cost and then some will go to Medicare if they don't go to a private insurer.
1
We cannot adopt the OK or Canadian health care system overnight and maybe never should as it's clear the medical professionals are paid less and care and wait times increase. It's all a trade off. But step by step to expand the ACA, medicaid in every state, require all citizens to carry some insurance and regulate the private health care industry as first steps. AND if the Bernie supporters stay home and pout in 2020, the next 4 years of trumpism is on their heads and they should self deport to Canada or somewhere where they can have their single payer.
1
Health care reform is not a one-time fix - balancing insurance coverage vs. controlling cost vs. quality healthcare will always be difficult and changes to the system will need to be continually reviewed and tweaked to improve the system - a public option should be a no-brainer (if Grandma gets it for free, why can't I buy it) - it also has the chance to reduce costs by adding competition to the insurance and provider payment marketplaces - with the experience gained from the Affordable Care Act, it is time to take that next step in treating this chronic problem
1
How much step-by-step is needed depends on the winning margin of those who would take those steps. The stronger they are, the more they can do in one step.
Yet by aiming small, they also risk losing the votes of the outraged public. That risk is as serious as the opposite risk of losing votes by too bold an approach. Voter perception of "more of the same promises with status quo forever" is as much a loser as "impossible pie in the sky."
I trust Warren to go as big as she can. Therefore, I can trust her downsizing.
However, that does not mean at all that I support the downsizing. It does not mean at all that I'd trust anyone else who promises less and says we can't do more.
I distrust the downsizing, and am inclined to distrust anyone who offers less in the first place. Warren is the exception, precisely because I believe she will go as big as possible, not because she is backing away.
3
I suspect Dr. Krugman is correct on this one. However, I also understand the desire to just pull the band aid off and go all in. Medicare, Medicaid, and the VA Medical System have proven to be both effective at delivering care and surprisingly resilient at resisting corruption, back room deals purchased by industry lobbyists, and profit mongering. Have these things happened? Sure, on occasion. But it's a lot harder when the comptrollers and inspectors general are all civil servants. And having to get any changes to the program through Congress tends to shed more light on the process than executives at private companies making decisions behind closed doors. So, if this is going to be a gradual process, there must be an extreme emphasis along the way on transparency around any changes, even seemingly minor ones. And government watchdog agencies must be fully funded and staffed.
3
According to the American Journal of Public Health in 2018, 45,000 people die a year from lack of health insurance. Many now commute to Canada to afford their insulin. We need health insurance that works so all can get health care.
Many seniors citizens can no longer afford their medicines and premiums. Medicare and the Part D drug plan are both increasing in price in 2020 along with supplemental plans.
2
The historic conditions for European "socialized medicine" were the destruction of WWII and its aftermath, which made possible a fresh start. The middle classes joined the working class in demanding health care, and the rich and powerful had been so weakened and discredited that they could not stop it. In England, where Churchill had been the very symbol of victory, the Labour Party defeated him and passed widespread social reforms they'd been wanting since the 1920's but never could enact. France had a discredited right wing, which enabled socialists to gain power. Italy the same, and Germany had had social legislation since Bismarck took the wind out of socialist sails by passing it himself.
Without a similar catastrophe at home, the US avoided widespread social legislation, and enough employers provided (tax deductible) health coverage to satisfy the middle class, and even unionized blue-collar workers. If black and brown people didn't have it, who cared? The economy was booming, and health-care was affordable.
It hasn't been that way for a long time now, but the foes of socialized medicine are entrenched, and can scare those who have coverage into voting against reform. Sadly, we'll have to get there piecemeal rather than all at once.
5
I think Chapo Trap House made a good point about Warren: before even being elected, she is already repeating the main error of the Obama administration: pre-emptive compromise.
The aversion of Dems to hard bargaining for what they claim to want makes me doubt their sincerity.
I new the importance of health insurance and that I must always have it because my parents, factory workers, got health insurance through their weak unions and for which they paid. I knew if anything happened to me, the only money available to me would be my health insurance. It is the only responsible way to think. Just as you have to have car insurance, you should be required to have health insurance. But McConnell/Koch Republicans fanned the fire of hate against the ACA by stating it was unConstitutional to require everyone must have health care, despite the fact that everyone must have car insurance and you can't buy a house unless you have home insurance and those same people never questioned the constitutionality of those requirements. ICA, which some people refer to as Obamacare was passed. Because my insurance company followed the ACA Law, my premiu ms went down AND I received benefits that were not included in my policy before: annual wellness exams for each of us, annual mammagram for me, annual flu shots;BUT these benefits became available ONLY because my health insurer followed the ACA law; few did and in states like Mississippi who didn't adopt the ACA law as written, few benefits accrued to them;all of the limiting of the ACA, which stands for "The Patient Protection and Affordable Care Act" was done by right wing Republicans, coordinated by Mitch McConnell, a long time Koch operative.
Even if both passed on Days 1, Warren's bill actually gets more people into a public system faster than Bernie's. Bernie also has 4yr transition period and calls for just adding a new age cohort each year: 55, then 45 then 35. Warren's step 1 transition immediately lets: 1) anyone who wants to buy in at 5% of income, 2) all children no matter income <18 years old 3) anyone 50 or older into medicare immediately.
1
E;izabeth Warren's intelligent analysis of our health care deficiencies starting with the Consumer Protection Agency, has convinced me from the start that she's' my candidate But I always worried about her lack of interest in retaining some option for personal choice. Now she's shown her willingness to compromise in a workable way. Isn't that what we need until more voters are ready to minimize profits to insurance companies, health care agencies etc, instead of changes for our huge population who live on the edge
2
The problem with universal healthcare is that 1/2 of the country doesn’t want to contribute anything to the health and well-being of the other 1/2. That’s why we can’t address the public good, the public is too polarized to be willing to do anything that might appear to cost them something and do some good for somebody else. Southern Strategy and the politics of resentment and hate got us here. And the only ones who benefit are the wealthy.
2
@jim
The polarization is intentional, created by the corporate/establishment elites as a deflection away from the real problems of America and their solutions. If Americans acted as ONE, the establishment wouldn't have a chance and these ideals would be achieved.
That is essentially what Bernie Sanders has always said, these ideals and polices and the change that comes with them such as the Civil Rights act, women getting the vote, the formation of the unions to get better working conditions were all done from the "ground up" never the "top down", in essence, a type of revolution that forces those in power to make the necessary changes that benefits all of the people not just the few at the top.
Rather than listening to the propaganda about maintaining the status quo, it is too bad that Americans have not studied their own history.
3
Not only does Warrens step 1 have an actual chance of actually passing the Senate since it can be done with 50 votes (can be done by reconciliation following Republicans repeal precedent) precisely because it is not putting the Health Insurance companies out of business, nor forcing individuals out). BUT then it actually gets more people into a public system faster than Bernie's bill. Bernies 4yr transition period adds a new age cohort each year: 55, then 45 then 35. Warren's step 1 transition immediately lets: 1) anyone who wants to buy in at 5% of income, 2) all children no matter income <18 years old 3) anyone 50 or older into medicare immediately.
The first step should be to strengthen the current Medicare, rendering private so-called advantage plans obsolete. Make it truly universal, with complete dental, vision, and hearing coverage. Allow it to negotiate drug prices to lower costs. Then make it available to all who want it. It wouldn't take long for private insurance to wither away from natural causes, rather than by fiat.
Of all social programs, health care seems basic. Certainly social security is important, but availability of medical care is pretty fundamental.
But every program is nothing but patchwork to fundamentally flawed tax rates. If the notion of human equality is important to you (you know:"created equal", "inalienable rights", the "American Dream" and all that), and if also capitalism and a sense of "freedom" is important,
then we must TAX FIRST. Figure out what to do with the money later. Increase my taxes and save me money. But, return all American tax systems away from the current regressive rates and back to the progressive taxes before Reagan that allowed ALL Americans to get wealthier.
Every specific social program is beside the point. Tax correctly first. Under capitalism, money makes money. Only a progressive tax will stop the inevitable inequality that a flat tax, or an inadequately progressive tax would create.
I hate to defend the drug companies, but drug costs make up 10% of total healthcare costs in the U.S., yet, most people seem to think that they make up most of the costs. If we negotiated the same drug prices as Canada for example, we would save a grand total of just 3% of total healthcare costs. Going to a single payer medicare-for-all will cut just 6%.
Look at Warren's original plan, if you don't believe me, going after the drug companies, destroying the insurance companies and going to government run single payer will yield a total healthcare savings of less than 10%, and that ain't gonna get us there.
I am all for much lower prices on drugs, getting rid of insurance companies and going to an all government system, but lets get real here for a moment, doctors, clinics and hospitals make up 65% of total healthcare costs, and unless we slash the fees paid to these entities as well as the trial bar association we will not have affordable universal healthcare like they do in Europe.
And, none of the Democratic candidates' plans really begin to address the heart of our healthcare cost crisis.
1
@Shend The big savings will be in terminating private insurance profits and reducing administrative costs. That's well known, many commenters mentioned it in this thread, so why do you ignore that?
The biggest problem for any reformer is that people have become fearful of change. Trump's appeal is based in part on claiming he's returning to a better time for America - and spreading fear of Democrats.
Considering there's darned little good news coming from the future, it's a hard sell that things can be made better, especially when Americans have been subjected to decades of messaging that government can't do anything right, and we can't afford it in any case.
Unless government, voters and physicians understand the basic principle that universal coverage means universal affordability, we are lost on all the talking points.
As a physician and one who is now (unfortunately) a chronic patient— it is absolutely clear our system is great ONLY for those who can afford it. That should raise flags not only among those of us who took the oath, but to those who profit off a system intended to focus solely on those with ill health.
2
Unless they've been doing their own research, voters don't understand Sanders' plan any better than they understood the Affordable Care Act before it squeaked through. All most are hearing is a) It will "take away my private insurance", and b) It will cost trillions of dollars and raise taxes. Although both have tried, neither Sanders nor Warren has been able to break through that wall of sticker shock, tax aversion and fear of change which the media, Republicans and moderate Democrats have built. So it is smart of Warren to put shock absorbers on her plan. If that puts her in the same lane as Biden, Buttigieg, Klobuchar and others, that gives her more oxygen to talk about her other plans. She is not just a one-trick pony, after all.
169
@abigail49 No, she is not a one-trick pony, and, even if she were, M4A is not the one trick. Her trick is understanding what part of the billionaire rentier class is productive and what part is not,and why. And she has proposed clawing back some of the ill-gotten rents.
https://www.economist.com/finance-and-economics/2019/11/07/have-billionaires-accumulated-their-wealth-illegitimately
"Three-quarters of billionaires’ wealth in advanced economies was fairly acquired. Still, rentier wealth has risen relative to GDP. Some countries are more cronyfied than others. ... in America rent-seeking industries made one in five billionaires and explain a third of total billionaire wealth."
Her biggest flaws are that her tone is neutral, her command of the facts is impeccable, and she can win.
9
@abigail49
Warren is simply tacking to the center. She knows she has to do it, she's been scaring people with the speed of her proposals on health care, so she might as well do it now. If she can expand Medicare in her first one hundred days, lets say lower the eligibility to age 55 - that would be a good test for both the government and consumers alike. We all need to see how this will work and how much this will really cost. Perhaps a copay option could be included for younger consumers to pay into Medicare coverage instead of private insurance. As long as Warren allows Americans choice to go private or public, and convince them that this is a step by step process - she will be better off and probably on her way to the nomination.
6
@abigail49
In reality, the ACA was not even an Obama nor democrat idea, but a Mitt Romney/(Koch Bros. funded)Heritage Foundation/Republican plan that, unfortunately, the democrats settled for when they could have done so much better for the American people, yet, failed.
I would submit, is it not time for democrats to actually come up with their own own plan especially something that is much better than just "Obamacare ll" and will bring Americans closer to what all of the rest of the "civilized" world is doing? You will NOT get that plan from corporate/establish/centrist candidates whose donors just want to maintain the "status quo".
8
Nobody complains about cures for cancer or diabetes requiring steps taken over years and even decades, because that is how solving health care problems actually works. The same is true of providing health care to everyone in this country. It requires steps taken over years and decades. President Obama and a democratic congress passed the ACA ten years ago. How fast did that ten years just go by? Incredibly fast. Take the step toward a public option now and the next thing you know we will be ready for another step. And that's how progress works.
122
@Anton Cures take time because discoveries have to be made, and one discovery builds on the previous ones. We know how to insure everybody.
7
@Anton Healthcare is far from perfect. But removing any and all profit motive removes the breakthroughs you reference in your very post. You have to choose - do you want cutting edge medical breakthroughs which cost money and leave people uninsured? Or do you want to cede those breakthroughs and have everyone insured in a government system.
I went to Northwestern University Medical School. There was a reason 1000s of Canadians came to the cardiovascular unit every year.
2
@Jason I don't know what that reason would be, since Canada has better outcomes on cardio care than the US.
19
Healthcare is not the same as health insurance. Right now we have Medicare which covers health care for all above the age 65, There is private health insurance which covers health care of over half the US population. There VA that covers the health care of veterans from the defense forces, there is medicaid for those who have no means to cover their health care. There is affordable health insurance supposedly for millions of those who cannot afford private health insurance or are not above 65 or are not on medic aid. Universal medical health care should be the goal and a government managed health care should be provided for those who cannot afford health insurance or refuse to choose not to pay for health care.
1
With respect Mr. Krugman, you are wrong! I am an American who has lived under single-payer system for many years and know what my family and friends back home have and are going through. The idea of incremental approach to health care for all is like saying bring down the Berlin Wall slowly and over a period of time so those on the other side have a chance to get used to freedom. Because that is what it is; freedom. freedom from worry about what life can throw at you. I have survived cancer and have a child in the autistic spectrum and if I'd have lived the last 20 years in the US, I'd be broke. Those I know in the US with good incomes may agree with your way but most today do not have the patience for all the waiting. Many still do not even understand how the ACA works. Freedom is far better than "wait and see".
166
@Tim Newlin: "In the long run we are dead" has no practical effect on economists or jurists.
3
@Tim Newlin
I have lived almost all of my 57 years in the U.S. and yet am considering relocating to a European country because of the cost of healthcare and also college (for my teenage son.) I have incurred huge medical expenses, and I'm tired of crossing my fingers and hoping I won't have any more medical issues. Mr. Krugman writes about how Obamacare mostly works for people, but what do people for whom it's not working do? For some of us, the answer is emigration. It's ironic because my parents emigrated from Ireland 60 years ago - I'm sure they never imagined that their children would return to the "old country" to pursue a better life. The American dream is alive for a few, but not most.
48
@Tim Newlin
I love this argument. It is spot on and one the Democrats should hammer away on. Americans suffer under total health care tyranny but claim to love their liberty! Incredible.
In New Zealand, with excellent single payer health care I can move wherever I want, start a new business , sleep on the street or whatever and health care is not in any way a consideration. THAT is liberty.
40
Warren scares billionaires and others with her tax plans, so they're going to be doing all they can to stop her. The resulting noise may keep people from paying much attention to her smart plan for gradual healthcare reform.
Insurance and Healthcare interests are defended by conservative Republicans, ranging from Senators to Fox Pundits, to neighbors down the street. I have no understanding of such self-defeating positions. Why wouldn't anyone want to pay a little more in taxes to be secure in the face of possible medical disaster? If not trusting the government is the excuse, I'm curious about what unfettered insurance companies do to earn trust, because that's what we're left with if Republicans have their way.
Healthcare costs ruin lives, yet Mitch McConnell thinks its time to remove the preexisting conditions protection we got from Obamacare. What a boon for insurance companies, to have a man like Mitch looking out for them.
The lesson is this: stay healthy, move to a country with universal health care, or pay the price here.
16
@Reliance The ONLY way to fix this problem is to make sure that ALL Congress [and unions] get the basic Bronze ACA plan.
9
@Reliance: In objective terms, the US spends twice the average per capita of other first world nations for inferior public health.
7
With all the discussion about what to do about health care, I have yet to read or hear anything that explains why corporations and employers aren't leading the charge for universal health care. I myself have never met a corporation that didn't love any potential cost cutting measure, even if (or maybe even especially if) it impacted employee benefits. I would think that they would be thrilled to be relieved of the cost and administrative burden. What is the motivation for them to cling to employer provided plans? Do they get especially generous write-offs? Do they love holding employees hostage with the threat of losing coverage ?
112
Dependence on your job on healthcare makes the employee fearful of risking hi/her job an SC depresses wages. It’s about control.
26
@Greeley
That's a good question.
3
@Ray Katz It's definitely a factor. So why isn't this being promoted as a benefit to Medicare for All/Universal Healthcare. Seems to me a lot of people would love to not worry about it anymore.
10
I think these incremental reforms are a step in the right direction. Taking away everyone's private insurance is too scary and too easily vilified to be a successful strategy for the general election. Warren (or whoever) should say, "I believe single payer is where we should end up. I've created a roadmap to get there, and a way to pay for it. But we start with what we can do. And if we want to do bigger things, we must deal with the corruption in our system first. We must reform our system so that our legislation is no longer written by lobbyists, and solely for the benefit of the corporations and billionaires who hire them. We must end the dark money flowing into our political campaigns, and amend the Constitution to clearly state that corporations do not share the rights of citizens, that corporations are tools to serve our communities, not the other way around, that money is not the same thing as speech."
Pivot away from scary "socialism" and redirect the conversation to reform of corruption-- a message everyone (but the billionaires), left and right, can get behind.
76
@Miker
People think health insurance is health care, which it's not, so they're afraid of losing it . Insurance provides high-priced access to healthcare, .Single payer provides direct access to healthcare for EVERYBODY. An example: What I DON'T get for pricy health insurance (many plans don't have vision, dental or hearing benefits) versus what i DO get for for single payer (no premium, no deductibles, no copays, dental, vision, hearing aids.)
Something like $5000 for health insurance, which is not health care, versus $5000 in taxes which is. It would probably be a "wash" for many people.
Let's allow Medicare to negotiate with the drug companies to set prices. While the drug companies talk about their millions of dollars spent in research, they are silent about the millions they spend on lobbying. Also, they conveniently fail to mention that much of their research is jump-started by the taxpayer-funded National Institutes of Health & other government health-focused entities. . Let's forgive 6-figure debts for medical student loans, for those who would serve where most needed. Let's give more latitude to nurse practitioners and physician assistants to help alleviate what could be shortage of doctors.
7
@Miker
This whole idea that Medicare for All will take control away from employees to keep their private insurance is nonsense. Employees now have no right to keep their insurance. Overuse of and caps on private insurance can effectively cancel one's private insurance. Moreover, the employer way decide to change insurance provider probably to get a cheaper (and thus less comprehensive ) one. And further, one's current doctor may decide that they no longer want to be in the network of the employer's insurance. There are lots of ways an employee can lose their insurance. The notion that the employee has control over their insurance is a fantasy.
With Medicare for All, there are no ways to lose insurance, there are no networks, and all doctors are available to all patients.
3
@Miker
Taking away people's private insurance is not too scary.
We do it to millions of people every year when they turn 65.
None complain.
I know lots of people - all republicans - counting the days when they GET to be in medicare.
This business of 150 million people wanting to keep their private insurance is a bunch of Carbon Fiber that the private insurance companies want to have troped around.
Some how we care about a 55 year old being forced to give up their private health insurance yet we don't care about a 65 year old having to do the same?
In fact they look forward to it!
How many people will do the work they dream of doing instead of the work they are forced to do to have health insurance? You know what they call that? Serfdom.
Nevermind the GOP worry about the road to serfdom, it is already here and they are the ones keeping us schackled to it.
5
Medical & psychiatric care ought to be a right not a prize that people receive if they have the right job or insurance. Whether or not an individual is legal or illegal, is of no concern. Think for a moment, how dangerous might a contagious disease be to the general population if someone cannot secure medical treatment? A lack of psychiatric care may mean that we have another one of what seems like those weekly shootings we all despise. The damage caused by one of those horrible shootings to all involved can never be denied.
With regard to the 'end' of private insurance, I would guarantee that employers would greatly cut back on the provision of that benefit and private insurance would die a natural death. I would not be sorry to see private insurance die because they charge huge amounts of money & then throws the insured to the mercy of the hospitals because various procedures & many doctors are not part of their limited network. Hence, the insured has no insurance for that procedure of the physician providing care. As many people are aware, if you are uninsured, you pay the highest amount for which ever variety of care, provided by any physician. Its time that all Americans open their ears, minds & eyes, & realize that medical & psychiatric care are a right not a privilege. You or a family member receives necessary care or you or that family member will start a slide down the ladder that includes, job loss, inability to pay bills, homelessness, and death. Republican MAGA!
The ideas I see here will possibly cost democrates the presidency. Critical thinking has no chance against ideology.
1
Even a 2-step plan could be a loser for Democrats if independents and some Republicans, worried that it would take away what they have and like, and vote to keep at least one of the houses of Congress in Republican hands. Without House and Senate buy in it won't go anywhere.
I am convinced that most people who ‘love their private insurance’ love it because they are for the most part healthy and only have to use if for trivial inexpensive treatment. If all of those folks who ‘love their private insurance’ had to experience serious problems such as cancer, organ transplants, experimental treatments, etc they would fall out of love really fast. Bernie Sanders and Elizabeth Warren both know what the most rational end goal is. A two step may be the most pragmatic way to get there but let’s not forget - Sanders and Warren are the ONLY two Democrats showing leadership on this issue by being AHEAD of most of the population.
1
A step-wise approach is doable, and gives room for mid-course corrections:
1- Expansion of Medicare to 55;
2- Expansion of MedicAid, including federalization if a state dragged its feet;
3- Authority for Medicare to negotiate drug pricing.
These are where the shoe pinches; over time I would expect Medicare to evolve legislatively into a de facto public option. In the meantime, catastrophic care (part A), routine and outside-the-office care (part B) - through private carriers or a public carrier - will keep us limping along. Yes, there will be premium changes - and this Medicare recipient doesn't really mind.
The problem I see with abolishing "private insurance" is what to do with the huge HMOs like Kaiser.
1
Medicare for all who want it, a tax cut for those who keep private insurance. Almost fits on a bumper sticker and will force the GOP to oppose a tax cut for mostly the rich. Private insurance will wither on the vine in a couple of years.
2
Thirty years an entrepreneur, twenty of which involved fighting with for-profit insurance companies to provide the coverage their contracts defined. From 1974 until 2000 (when I moved to Medicare) premiums exploded, co-pays blossomed and bogus "disqualifications" on legitimate claims almost doubled. (We ALWAYS won those contests, but at big time costs in manpower to wage the appeals. I always knew many people didn't have the ability to do that.)
Therefore I look with informed askance at the for-profit health insurance companies. Hey, they are FOR PROFIT, and it's time for that one form of insurance to be totally FOR US.
1
If enacted as laid out by Warren last week, this approach is fairly reasonable and would probably be the most likely way this country grows to accept any form of universal healthcare.
The problem is that Warren herself chose to treat this modified healthcare proposal as a news dump - quietly releasing it on a Friday in the middle of a news cycle predictable dominated b y impeachment hearings.
I agree with the modified plan. I'm not entirely sure Warren does. She has a lot of heavy lifting on health care in front of her.
- Deficit passed the 23 trillion dollar level on Nov 1, 2019.
- Heathcare costs overall are at 3 trillion dollar per year and increasing on average approx 5% a year over year. Thats approx 10-11K per every man, woman, and child in the country.
- Infrastructure is degrading as I write this.
Now tell me how we can afford any of these new programs, whether Heatlhcare, free college, paying off student debt, without first dealing with the deficit.
1
@TH
It really isn't rocket science. Universal health care costs less in total and per person, like everywhere else it has been implemented. It's not as if the money isn't being spent, and the scope for cutting spending on the fat that doesn't go to health providers (ie middlemen) is enormous.
How many times do you need to see the numbers?
2
Krugman has it right, As usual. The middle is where elections are won, as; see recent election results if you need convincing.
"Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger."
This is the approach everyone I have talked to about health care--in and out of the health care professions--supports. It's practical, incremental, gives a chance for flexibility and adjustment along the way.
Also, everything I have read about health care globally indicates that it is most important a nation's health care system is not a one-size-fits-all, but is in keeping with a country's culture and values. Maybe that is why there is such variation among advanced countries in exactly how their universal health care systems work.
Unfortunately for Warren, first impressions matter and once established, are difficult to change. People remember her as being adamantly all-in for going cold turkey on Medicare for All and taking away private health insurance to get there.
Evidently, she listened (one of her many fine qualities) and has adjusted her plan to be more realistic and acceptable to the public. But it will take a herculean effort on her part to convince people she really wants Plan B now.
Plus, she will look "indecisive" to some, which the Republicans will milk for all its worth, as a wink-wink indecisive, woman who can't make up her mind--so vote Trump (never mind how many times that pants-on-fire-liar has flip-flopped and reversed his edicts!
Dancing a 2-step is more difficult than it looks. But, I wish Warren well!
What's more important right now? The main goal should be to vote Trump out of the White House, and winning the Electoral College requires the Democratic candidate to win six swing states -- Arizona, Florida, Michigan, North Carolina, Pennsylvania, and Wisconsin.
Unfortunately, no matter how much we desire Elizabeth Warren or Bernie Sanders, neither poll well with moderate conservatives in those states. And we need those votes as we did in 2018. How can we risk turning them away?
Let's give Ruth Bader Ginsburg a chance to retire, keep the balance of the Supreme Court, and then move onto Medicare for All.
1
Both the Kentucky and Louisiana elections were exceptions. As Paul stated, the Kentucky incumbent governor was (like trump) highly unlikable, thus lost the election. The incumbent governor of Louisiana is essentially a republican. There are many independents and responsible republicans out there who will vote for trump if the democrats fail to offer a candidate that is willing to work for all of us. Incrementalism, courtesy and patience will do the job.
2
I'm not sure of your argument here for incremental movement toward Med-for-all; it might work in the sense of the Warren details.
But one only has to look at the Medicare Website for a few minutes to see, that even in its current state, regular Medicare is a nightmare of detail and wasted detail wih Medicare Advantage (piece of junk) and numerous supplemental plans each with their own details and even varying from state to state. One will see there a multitude of confusion and conflicting plans and we haven't even gotten into the drug plans. To understand those pages would take a Ph.D. (and I have one) to fathom. Part A and Part B and supplement plans A, B, C, D, F, G, K, L, M, N and all different. And then one must study co-payments and co-insurance and deductibles to discern these all from each others. This goes on and on and on for pages with exceptions for this and for that. This is preposterous and in a modern nation like ours and should not occur. A simple Med for All simplifies, does not have stock holders to pay, or execs receiving 20 million a year and many, many more economic advantages and efficiencies.
For some laughs, here is a typical statement on the Medicare site:
"Starting January 1, 2020, Medigap plans sold to new people with Medicare won’t be allowed to cover the Part B deductible. Because of this, Plans C and F will no longer be available to people new to Medicare starting on January 1 If you already have either of these 2 plans (or the deductible...
4
Defining the perfect healthcare plan is a trap for voters opposed to the hateful and destructive policies of Trump and McConnell. ANY Dem. candidate will implement important improvements to the current healthcare system, will restore many of the environmental and other protections we all need, and will stop the wholesale corruption of the current regime. Even more importantly, ANY Dem. candidate will stop the destruction of the ideals and possibilities of America. The real healthcare disaster facing us is the environmental, medical, moral and economic devastation we all face if these men remain in charge.
1
Neither Sanders' nor Warren's plan is "Medicare For All". Both should stop using the slogan. Few "younger" people, have little understanding how Medicare works.
1) It isn't free. Except for those with very low incomes who get a subsidy, people on Medicare have to pay a monthly "Part B" premium of between $135 (most people) and $460 (highest incomes) which is deducted directly from Social Security benefits. (Sound familiar?) Those that do not qualify for Social Security get a monthly bill.
2) There are copays and deductibles for services--just like private insurance plans offered by employers. In fact, standard Medicare copays are usually higher than private, employer-based insurance plans.
3) There are no automatic drug benefits, except for drugs administered in a hospital.
4) Private insurance plays a huge role in Medicare. Recipients can pay extra for Part D drug coverage through a private insurer. They can also buy a private "Medigap" policy to soften the copay and deductible blows.
5) Medicare offers a "Part C' option in which a private insurer agrees to cover all costs usually associated with an employer-based plan (typically HMO or PPO plans). This is the choice of about 1/3 of all Medicare recipients. My own plan is nearly identical to that offered by my former employer (and provided by the same insurer). If a genuine "Medicare For All" system allowed employers to offer their existing plans under "Part C", much of the angst about losing coverage would vanish.
6
Private insurance sounds wonderful, who wouldn't want such a thing? But when this type of health insurance is described accurately -- for-profit insurance --- we come to see why the U.S. has the highest insurance cost of virtually every other nation, with poorer outcomes than many. For-profit insurance places layers between patients and the care they need, a layer of insurance company boards demanding ever-higher stock prices, and layers of employees trained to routinely turn down requested procedures, starting a long chain of doctor/insurance company communications until (hopefully) the procedure is finally approved. But the term "private insurance" widely used by legislators, presidential candidates and the media, including Dr. Krugman, in no way conveys how this type of insurance stacks against the patient carer. Can we please call for-profit insurance to be identified by its rightful name?
2
Makes sense to me. But a President Warren would need to fight hard for Step Two.
Giving more people access to a broken, wasteful, low value system, while a necessary step. is throwing good money after bad. and will not afford them equitable access or protection from sickcare induced financial hardship or ruin.
Step one is fix the system
Step two is fund it.
"Warrens approach?" Warren's approach? Krugman has been losing it for a long time and this is just inexcusable. The most striking thing about Warren's first plan was how it resembled what Bernie Sanders was proposing except she didn't acknowledge the cost and growing pains that would come with it. Then she had to make the cost and pain go away and came up with a ridiculous set of projections and funding mechanisms that could not be taken seriously (as much as this newspaper tried). So, under pressure she came up with a new plan which is striking in that it resembles what Biden/Klobuchar/Buttigieg/etc. have proposed. The candidates that Warren mocked for being too weak and centrist.
Warren was given a pass for months while real criticism would have exposed numerous weaknesses. She rode the wave and went too far with her healtchcare plan and revealed it to be a house of cards. That is the lesson here. We don't need Krugman and others continuing to prop her up.
3
I agree with the thrust of this article. I see it as inevitable that eventually the US will join the rest of the western democracies in having a single payer health system and I believe it should, but promising to ditch "Obamacare" immediately and replace it with something better makes no sense whether you're Trump or Sanders.
1
M4A might be a great idea, but without winning elections it will go nowhere. Incrementalism is the only way things happen in this country. All the arguments, charts, personal stories in the world are not going to get the population of the US to go full Bernie. Period. If we eventually get to M4A great, but let's improve on what we have in place first.
You might not like this situation, but that's where we are.
1
Are any of the people advocating M4A actually ON Medicare? It's hardly cost free/insurance free if you actually need critical care, and most use private insurance for a supplement or advantage plan . I am paying $6K a year for a supplement, plus Part B premium, Plus Part D prescription coverage.
Get real people, M4A is not a panacea.
6
In the first 100 days of a Warren administration, we will have the chance to buy a Medicare plan. For those who fall below $25,000 (or $50,000 for families), we will qualify for free medical care.
If you are an entrepreneur, an artist, a photographer, an inventor - someone with a hobby, an idea, a passion - you can now quit your corporate job and start that business without the fear of losing your health insurance coverage.
This is the transition plan that Warren offers and it is smart. It goes beyond what any other candidate is offering. The other candidates will no doubt attack the plan, but each would, if elected, steal ideas from Warren's plan to help improve our healthcare system.
3
I am so tired of all this hand-wringing about Medicare for All, the tired old arguments that Americans "aren't ready for it" or that they "want to keep their old insurance." Last year, private health insurance premiums for individual coverage averaged $440 per month or $5,280 a year while premiums for family plans averaged $1,168 per month or $14,016 annually. For older Americans the cost of individual policies was higher -- $6,492 a year for age 45-54 and $9,480 a year for age 55-64. Sure many Americans have employer-paid or employer-shared health plans so they don't bear these costs alone. I guarantee you that a public option would eliminate all employer-paid or shared policies overnight. But the Medicare withholding tax for a nationwide pool in which everyone was covered would be a lot cheaper than private insurance, wages will rise when employers are freed from paying for the health care of their employees, and the insurance industry -- yes, industry, because health care in this country is a business -- will be left with providing supplemental insurance to chose who can afford Cadillac plans.
4
I too am tired of this incrementalism approach that Krugman pretty much always seems to advocate. Our health care system is a mess. A recent article pointed out that 34 million Americans knew someone over the past 5 years who had died from a lack of medical care as they had no insurance. Diabetics having to go without or rationing their insulin because they can't afford it. 500, 000 medical bankruptcies per year even with folks who had private health insurance? Every other developed country has universal health care systems for their citizens with better outcomes for less money. No, they can do it and so can we. Medicare for All now!
1
Any transition would be a major accomplishment in this culture, but by all means: yes, go for it. If the original public option provision of the ACA had been adopted, very likely market forces would have brought us to Medicare-for-all by now.
1
The problem for Warren and Sanders is Medicare for All PLUS free college PLUS education loan forgiveness. They will lose to Trump.
3
I wish Krugman would not stoke divisive impulses as he did in 2016.
We can have intelligent discussions of the benefits of doing away with a private insurance system which is still designed more to extract wealth from captive customers rather than promote efficient and equitable healthcare, as opposed to incremental approaches, which might recognize this, but see troubles getting there, especially through the current fog, and predict more legislator votes for less ambitious reforms.
But when Krugman keeps portraying Bernie supporters as rigid ideologues, as purity pushers, when in fact we are a much more diverse group, Krugman does us all a disfavor. He opts for ugly. He stokes anger. He divides a party and gives ammunition to Putin-style divide and conquer operatives. He can stop this and rein in his rhetoric so that it respects us all.
We can have a sensible conversation. It's time to have it.
@M Peirce
It's long past time for Bernie supporters to have sensible conversations. The rest of us have been waiting.
1
This article is Paul Krugman doing Ms. Warren's bidding, literally. They have been in contact since the restructuring of her health plan.
2
I like the President-gets the best HC at moment's notice-recently. He's obese and older and under Impeachment Inquiry-- you'd hope for lightbulb moment-- as in what it's like to need care desperately?
The revolution will be Fabian.
It will likely take much more than a two-step, given the history of US health care dating to Medicare's inception: https://www.asaging.org/blog/political-history-medicare . People have been in combat over plans for many decades.
Also, there are sound ways to cut our enormous administrative burden well before we get to Medicare for all: https://www.asaging.org/blog/political-history-medicare ("Reducing Health Care Costs: Decreasing Administrative Spending," David Cutler, Senate testimony, July 2018).
1
This is an important analysis of Warren’s plan that will be drowned out by constant repetition of “She’s going to take away your insurance even if want to keep it!” “20 trillion dollars” “Socialism!!!”
And some of that is coming Democrats, no less.
https://www.twopartyopera.com/comic/yes-we-can-as-amended/
Anyone ever hear Republicans talking about modest goals?
Why don't you mention Kamala Harris' Heath Care Plan?
Any proposal that leaves something like this as a possibility is morally bankrupt: https://www.theguardian.com/us-news/2019/nov/14/health-insurance-medical-bankruptcy-debt
Organize people around how this nightmare, which can hit any of us, even if "insured," will never end if profit runs the system. You won't have to work very hard; it's only rich people who poo-poo all this stuff and advise we defer and defer.
Know why? Because Krugman doesn't have to live this reality, being a tenured, famous, wealthy Princeton professor and NYT op-ed guy, a platform for many paid appearances, book contracts, and the like.
Sorry, it has to be true. Otherwise, he'd be up in arms about the fact that this garbage happens post-Obamacare.
If my fellow lefties expect to get any of this jazz done in ways that make any sense at all, they better start studying up. Because a lot of these claims and demands are just plain crazy.
His protruding stomach, bone spurs, mental condition, hair color, absurdly-long neck ties and total lack of a sense of humor remain a matter of grave concern to me.
https://www.nytimes.com/2019/11/18/us/politics/trump-health-emergency.html?action=click&module=Latest&pgtype=Homepage
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So, the takeaway, before we even go to the general, is that Warren is a liar. Nice
What really puzzled me is the fact that no politician in America is required to study political science and philosophy. As a result, we have so many amazingly "uneducated even idiotic" candidates. A communist Kshama Sawant just won the Seattle district 3 city counsel election positioning herself to nationalize all major corporations and private businesses. So called socialist economy she is trying to sell is in fact Communism. She obviously has never lived in a communist country before and experienced its spectacular horrors unlike many of us who escaped from it and came to America. It really angers me to have these unqualified and irresponsible people trying to lead us into madness.
1
Dr. Krugman begins his opinion with a story about Governor's elections in three states, explaining that this is "bad for Trump".
That....succinctly explains why Dr. Krugman is completely wrong about Health Care.
He's attempting to make Health Care a political issue. Its NOT. The REgressive people, such as Dr. Krugman, have made Health Care a political issue for over thirty years.....and have achieved.....Nothing.
...
It is even worse that Dr. Krugman insists on confusing Insurance Plans for actual Health Care. Universal Health Care....much like Universal Life Insurance......is simply not there for the person that buys it........its compensation for the inevitable events in life.......ie.....accidents....and sadly.....death.
We dont need Universal Health Care......
The whole nation has been clamouring for AFFORDABLE Health Care.....and politicians, including a recent President, keep fooling us with Insurance.
Think, people, think.
The politicians , and Dr. Krugman, are not understanding the issue.
Are these the same political polls that had HRC winning the White House?
1
Funny.
Liz brought her original insane plan to Paul to do the math and he was pretty much all in. Even though the numbers don't add up and the proposal amounts to political suicide and four more years of Orange Pinocchio.
Now that she's walked it back, he' walking it back.
Way too facile, Paul.
1
The Democrats' programs would take care of the "least fortunate" first. The slackers, the unemployable, the self-disabled would go to the front of the bus. On the other hand, those with jobs can take out loans, sell their homes, get a second job. For them there is "under the bus".
"How sweet it is..."
Maybe the same goes for the impeachment investigation.
It might just be too much for some people to absorb to have such powerful testimonies, one after another.
By having more time between key witnesses it would give voters a chance to better understand the implications of what is being said and let it sink in as discussed in this NY Times piece:
‘No One Believes Anything’: Voters Worn Out by a Fog of Political News
https://www.nytimes.com/2019/11/18/us/polls-media-fake-news.html
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“We chose to go to the moon...eventually...but we aren’t going to make an effort now...because I don’t really care...”
How inspiring!
Some numbers:
$50 TRILLION - That's what we can expect to spend in the next 10 years with the present system. (We spent $3.65 TRILLION last year and medical inflation is between 5% & 6%.)
$35 TRILLION - That's higher than the highest estimate of the 10 year costs of the Full Bernie, and that includes startup costs.
????? TRILLION - That's the estimate of the 10 year cost of the vague public option plans pushed by the moderate candidates.
$25,000 and $45,000 - These are the costs of a stent op and a by-pass op which we have recently discovered are no more effective than medication (and more dangerous). This is merely one of many examples of medically unnecessary tests and procedures that we do since the data that we need to discover them is held secret by private insurance cos.
$5,300 and $1,200 - These are the prices of 2 echocardiograms I had, one brief one at a local hospital & the other, much more thorough, at one of the main Harvard teaching hospitals in Boston. See https://www.nytimes.com/interactive/2014/health/paying-till-it-hurts.html
for a full analysis.
200,000 - This is the number of people who die each year in the US "from medical conditions which there are recognized health care interventions that would be expected to prevent death."
530,000 - Number of families that suffer medical bankruptcies in the US each year.
How many people have to unnecessarily die, have to go into bankruptcies, how many TRILLIONS do we have to waste before we get real progress?
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However pooh-poohing single payer altogether and saying it will never work sets us back and why I won't support Democrats who denigrate it. [cough Biden cough]
Might diabetics and their families—that is, MILLIONS of Americans—be motivated to vote for Sanders and Medicare for All because “going slow” means for them “certain death”?
Krugman is really on to something with this column. Healthcare is a worry for most adults, as is elderly care. If you are very wealthy, no worries. But otherwise, middle-class voters, worry. Trump claimed he would do better than Obamacare, but all he and the GOP have done is to weaken Obamacare. I hope the voters remember this in Nov 2020.
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As a Bernie supporter I agree that achieving a single-payer system will take years, perhaps longer. But with no evidence given, Krugman makes the ridiculous claim that all Bernie supporters will resist anything but all or nothing on Medicare for All. The only thing "predictable" here is Krugman taking another opportunity to bash Bernie and his supporters. Go ahead, make the world safe for the corporate Democrat approach and make Trump's election more likely. But let's forget the important role Bernie has played in trying to lead the Democrats out of the neoliberal desert.
That GOP Supreme Court judges gave GOP governors the right to play God by depriving millions of healthcare (opting out of Medicaid) is inhumane and immoral.
How many suffered or died needlessly?
Expanding health options matters, unlike gifting tax cuts to billionaires and greedy corporations.
Here where healthcare is a basic right we are seeing incrementalism. Once you have the universal coverage the tweaking starts. That is why the right has barred the door because knocking down the door is just the beginning.
I wish the left knew their history as well as the right unknows their's.
Our healthcare for all began in the late forties and we saw the doctor strikes in the early fifties and the rest is history. The tweaking now has our doctors now leading in extolling the virtues of our system.
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Yes she is giving up Medicare for all. It was and is a stupid idea for a host of economic, social and political reasons. Krugman who is carrying a torch for Warren is just putting spin on her retreat. Whether we like it not we are where we are and this makes an incremental approach the only sensible one. It's always more rational to aim for a smaller public good with a high probability of attainment than for a larger one with a very low probability of attainment.
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A multi stage approach is the way to go. Every stage is a prerequisite to the next level. Sanders approach is not only dead on arrival but will be buried. I can’t understand why he wants to destroy his own initiative by being stubborn, stupid and selfishness. He should throw his support to Warren and work to bring to realization of his initiative.
Why is PK now talking out of two sides of his mouth. Although he is coming around to the right position this was what moderates were saying all along. But seeing because he is backing EW he is now changing like her.
Paul, unless Democrats address the COST of health care, neither an incremental approach nor single payer will amount to a hill of beans. We must stop the consolidation of health care providers and the ridiculous prices that sustain them.
The problem with incremental steps is that the health care system that we have is a complex one in which the various parts depend on each other. If you change one part too much it undermines the others. This is not an argument for making no changes. The system is seriously flawed and is crashing before our eyes. We can make some incremental changes, and they will help many. But they will not stop the system from crashing.
The issues then becomes how best to manage the crash. Some major structural changes will be needed to transform our health care system into the sustainable, fair, and quality it can become. So let's prepare for those major changes as soon as possible while we stick our finger in the dam.
Let me repeat what your proposing back to you. There is probably sufficient room in the electorate for the govt subsidized profits of the private insurance industry to be politically viable for at least another election cycle. An inspiring column if you ignore the millions of sick and dying citizens and the wealthy plutocrats why benefit.
Incremental is wrong. The kind of systemic institutional change we need must happen quickly. The misguided (brainwashed) people who think they don’t want universal care (that every other advanced nation in the world enjoys) will quickly see how much better it is. Do you let a patient with cancer take an incremental approach? No. You get in there and remove the cancer and attack the issue with aggressive therapy. Our corporate for-profit medical system is a cancer on society. Get rid of it as quickly as possible!
We all love the idea of freedom. I grew up in a suburb listening to western shows and thrilled by the idea of riding out west and staking a claim (to some tribes acreage...) and making a happy life defending it with a never miss rifle. If I got hurt, some woman would put moss on the hole, I would have fever for a few days, and always recover.
Wake up, boy. Health care is very complicated and generally more beneficial than in the Old West. You can't expect to walk into the ER and demand a comfry compress for free. So it is important that we have a serious discussion about what we mean by free when it comes to health care. Choice? Of what? Control? Who is choosing? Doctors have been moping about losing autonomy since Morris Fishbein in the old days of the AMA. And is bankruptcy one of the acceptable risks of freedom...for the country? Fairness and trust seem in short supply.
US healthcare , as it is ,is doomed to total failure .
American healthcare is the most expensive in the world , of mediocre quality , with millions of Americans uninsured and many more underinsured.
The great majority of Americans are worried about healthcare insecurity, chaos ,continuously changing rules .
We need a nationwide healthcare system that is accessible and affordable to every American, this can be privately or publicly run.
Private health insurances will be options available to whoever wants them , like in many European countries where National Healthcare Systems doesn’t exclude a parallel private coverage .
Prices for “ everything medical “ in America are grotesquely absurd , with 25% of expenditures on red tape !
I don’t know of any country where the sick must get involved In countless phone calls or inquiries to make sure that the care they need is going to be paid by their insurance carrier .
Wake up America , this rapacious greedy system must be stopped soon!
We are a plutocracy. We can wish all we want about great change in our healthcare but let's get back to reality; big money owns Washington and now has a death grip thanks to Citizens United. No our politicians tell us what we want to hear and does what their big money lobbyists puppet masters tell them to do. No matter who is voted into office our healthcare system is going nowhere fast.
Threatening to throw millions of Americans off their private insurance plans overnight and totally restructuring the system at a cost of trillions of dollars is one of the best strategies to grant the current mega-disaster in the White House a second term.
Democrats need to negotiate a balance between aspirations and realities.
The so called "moderates" all share the same single issue platform, that Warren and Sanders are too radical, otherwise they just represent an anodyne reset to the Obama years and that's about it. It's also no coincidence that they are gulping furiously at the corporate trough, with Deval Patrick as the latest gulper nosing his way in. Unfortunately, the world has become that much worse of a place in the last three years and restoring Obama's Nixonesque policies will not suffice. Providing a transitional healthcare program is smart on Warren's part because she robs these lackluster "safe bets" of their one cavil. They might actually have to stick their necks out and come up with some concrete policies of their own.
This country was founded by people so fed up with a Europe that could not, would not give them opportunities, truly, people who had nothing to lose or were deported here by an intolerant ruling class.
Has it come down to America now being the same intolerant, lazy, feckless machine that ground people down to the point they'd risk coming to the great experiment that was America?
Anyone who cannot bring themselves to see that plans like Warren's are the only way to both defeat trump and to overcome once and for all the chiseling away at the foundations of what this country is all about: creating opportunities for everyone to make their lives better.
I liken the practicality tempered bravery of Warren to be the same hand steadying vision that founded this country. About time after a brazenly incompetent Trump, the culmination of the deceit of Reaganomics, and the mealy mouthed ever more right leaning moderate Clinton then Obama.
She's not as out there as Sanders but not the empty smile of the too old Biden and too young Buttiegeg.
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Putting together the pieces of a life of poverty:
1. Food
2. Shelter
3. Healthcare
4. Job
Without the first three, the fourth will not seem attractive.
Sometimes, it pays to put the cart before the horse.
We don’t have a Healthcare system. We have a profit based, illness treatment system.
No one is talking about reducing the burden of chronic illness by improving the health of the American population. Pay attention to our food supply and disincentivize processed foods. Educate youth regarding the necessity of physical activity. Everyone should leave high school with a personal plan for fitness that works with their interests. We need to stop billionaires from sucking the economic resources so ordinary people enjoy increased leisure time to attend to health instead of endless job stress and financial worry.
1
Well let's see:
1) Will MFA save the country money? Probably. Will MFA cost the individual tax payer more, likely a lot more? Also yes!
For all claims all the money to pay for this isn't coming out of corporate or the pockets of the rich. The working class isn't deficient enough to believe that corporations(Who always have seat at the table) are either going to increase worker's pay by what they paid for Health insurance. A no one who pays attention to how things work in this country believes corporate taxes are going increased. When you conclude that how it will be paid for is so much hot....air. You wonder what else is ?
2) For those trying to claim Govt. efficiency will save money and provide better service have never done business with the VA or any number of other Govt. departments Efficiency & quality are not their hallmarks, Ineptitude & passing the buck perhaps, but not efficiency.
3) Next for all those calling for a VAT. You put 20-40% sales tax on everything they have to buy (And it will end up on everything) And those who are barely getting by now? Well torches & rioting in the streets is not unlikely. Most people who work for an hourly wage can't afford that level of tax.
This isn't Europe folks, STOP pretending it is.
4) The question isn't whether the proposal will save the country? It will! It is whether on the individual level it will cost more or less? Pretty much everyone who pays attention is pretty sure individuals will pay more a lot more!!
It is actually clear that individuals will pay less, considering that healthcare as whole will cost less. Right now according to your logic we all pay for the healthcare and profit it's generates through taxes, premiums, deductibles, co-pay. In M4A we will pay only taxes that bound to our income, and because the cost will go down we will pay much less, except high-income people and corporation. And if corporation will not increase the salaries is more reason to tax them more.
Agree that reforming Healthcare (HC) will take multiple steps, but unfortunately more than 2 viz:
1. Combine all fed HC insurance (Medi-care/caid, ACA, Tricare/VA, Fed Emp Health Insurance) to increase efficiency... then add 'public option' for both group + private insurees,
Note: Limit benefits to true insurance (e.g., not eyeglasses, canes, vitamins/supplements, OTC drugs, et. al.)
2. Eliminate fed tax deductions/credits for all HC payments (i.e., only HSA/FSA tax deferrals) to cut cost inflation, end counter-productive subsidies,
3. Create universal, cradle-to-grave catastrophic, chronic, preventative care system w/ savings from #2 above + employer contributions + per capita tax (not work-related) of 8-9% to fund it (w/ subsidies for low income/poor citizens),
4. Use purchase leverage and incentives to control HC delivery costs & improve quality/outcomes, including RX + DME.
What most people know about their health care coverage is based on their personal history. They don’t know is all the twists and turns they will face in the future. And, in particular, few know what happens when the going gets real tough. It is a truism that insurance is most important for the really big stuff which most of us know next to nothing about.
Because few of us know what we have, we are not in a good position to judge what we want. Even if we did the research, we’re in the dark about the expensive drugs, the specialist across the country, the newest procedure, or the doctor who screws up. And when we just can’t pay, we don’t know ithey will negotiate.
Obamacare was a 900 page law. Moderate reform and Medicare for all will also be incredibly complicated. And most of those who talk Canada and Europe have no idea what happens there when things get bad. So, se talk life expectancy or what happened to someone we know or something else that is just a clue.
So few of us know what we have and even fewer know how any of the proposed options will work. So we are sitting ducks for candidates whose plans are designed to get them elected and are long on promises and short on details. Basically, It’s just trust me. And my decision will pretty much be a wish and a prayer.
Oh! I see, now you do support a Medicare for all plan after all!
Good for you Prof. Krugman!
Yes. I mean YES! This is a winning strategy. Thank you. Now let everyone know that Warren really does have THE plan.
I agree that we need to make the shift to single-payer methodically, because that is realistically how something this grand will actually happen, but let's get going!!
My husband and I pay a $22,000 premium per year for health care "coverage". Between the current exorbitant prices for various health services and the insurance company's limited "covered costs" that don't nearly match charged amounts, and the deductibles and co-pays, that ridiculous premium represents just the baseline of our yearly healthcare expenditures.
We are basically paying to protect ourselves from going bankrupt due to a catastrophic health event, which is statistically of low probability for healthy, non-smoking, non-drinking, exercising, low-body-mass individuals like ourselves.
How can this be a functional or even logical system--paying a non-medical middle man for permission to be treated for only the health care services that these accountants decide are necessary? We're flippin' mad that this is considered the best health care system in the world, especially because there are millions still un- or under-insured!
Take our 22K and pay health care providers/hospitals directly for services and get rid of the expensive, ridiculously unnecessary go-between! Private insurance is a scam, people!
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As a practicing physician who has been on the front line, and in the trenches, for years, I have earned the right to say that the current "debate" on healthcare is incomprehensible, another example of how Democrats can always be relied upon to shoot themselves in the foot.
Warren and Sanders do not have to say they want to eliminate private insurance, they do not have to say that taxes will have to go up. The public option of Medicare-for-All would be paid for by employers, as we show in our book "Healing American Healthcare." Furthermore, the additional costs of healthcare for all would NOT be $2 trillion a year (Warren) or $3.4 trillion a year (Buttigieg) but NEGATIVE $i trillion a year (Eichhhorn and Hutchinson). The Warren/Buttigieg numbers come from flawed estimates form the Urban Institute, and it is dispiriting to see them still promulgated.
The fact is, whatever the pointy heads say, universal healthcare can be offered in the US for 12% of GDP, same as Switzerland!
Read our book, we have sent it to you often enough.
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The instrument most employed by American doctors is The Gouge.
Warren's bluff was called.
She blinked and folded; gave away her bargaining chip. She now begins negotiations halfway across the table (if even that).
Incrementally.
More band aides, duct tape and profits.
Thus the reason HC stocks rose the day she capitulated.
Tried to hang and be a rebel.
Glad that phase is over.
By the by Paul, where/when has Sanders ever said he won't negotiate on M4A?!
You just pass this off as if it is a given. Yet nothing is further from the truth.
1
I think she is very thoughtful to address concerns of voters. Much more than Buttigieg and Biden who are yet to define their public option, and who despite telling that everybody can sign up for this, actually designed the option only for low-income, very similar to Medicaid, leaving other people to suffer through overpriced system.
Don’t get too excited Krugman, in the past 100 years there has only been four Republican Governors in Kentucky, and none won re-election.
as a non american watching the health care debacle--for decades--in the united states of hysteria, i still shake my head at the ongoing craziness of having a national health care plan.
seems the self proclaimed greatest country that ever existed--in every imaginable way--is incapable of having a system that would move the usa from way way down in life expectancy, infant mortality rates and earlier detection of serious medical problems.
OMG look over there, there's a socialist!! run, run for your life.....
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@brupic misleading...when i wrote way down i meant down the list.....as in from 45 or so to a lower number
1
Organize the people and you'll be amazed what becomes possible. Look what Trump's done, with just a core base of 35% of the country.
Enough whining and pussyfooting. You come to the table asking for 200% and make the other side spit blood to go down to 95%.
But Krugman likes IvyLand, where no icky social movements of non-professional-class types ever impinges.
If you’re going to quote Pelosi to explain what she meant, you should use the full quote, not the partial one:
”We have to pass the bill so that you can find out what is in it, away from the fog of controversy.”
It makes what Pelosi really meant quite clear and reveals the dishonesty of how the right wing media willfully pulled it out of context and lied about its intent and meaning.
Krugman looks out and sees 2 options: Bernie and zWarren. It’s Warren because she is moving away from MFA. What? False choice?
What happened to all the others? Paul I’m not sure but I believe the position to build on ACA has been the position of a majority of Dems. At least after the first debate.
And what does it say that Warren first had MFA cold, then had to regroup and prove she had her numbers right and now has an all new proposal that sure looks like....Biden.
What parts of ACA are so dear to all Dems? High premiums? High deductibles? Complicated system of subsidies that requires guess work if you in gig economy? Mandate when people have to pay for not able to afford the insurance?
Let's do it. Let's do the Health Care Two-step. The greatest thing since the Brydon Two-Step (for amphibians).
The United States is the only advanced industrialized nation without a national healthcare system paid for by taxes. The rich paying more, but they can afford it, and still have lots remaining in their pockets after taxes. The United States has a two tier system based on your ability to pay. If you are poor, you are out of luck for equality in healthcare. Sure there is Medicaid, but a huge cadre of doctors avoid the patients with Medicaid like the plague.
For example, I was called to the operating room of a hospital that I normally didn’t work at to care for a 4 year old who swallowed a coin and it was lodged in his mid esophagus. The operating nurse told me that their ENT doctor on call had the emergency room doctor admit the boy, only to refuse to operate on him when the doctor found out the boy was covered by Medicaid. I canceled my clinic patients and came to this hospital to remove the coin. I have lots of stories similar to this.
My criteria to evaluate the healthcare proposals of various candidates is simple - if the healthcare proposal allows for “cherry-picking”, segregating, or discriminating patients by health “professionals”, hospitals, clinics, or health insurance corporations, then it’s not worth voting for that candidate or proposal. Bernie Sanders’ and Elizabeth Warren’s plans (Medicare for All or “AMERICARE” as I prefer to call it) are the only plans worth considering. The other policies are “defective products”, and shouldn’t be considered.
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When you say single payer, do you know what you are advocating for in the end state? I have worked in and for single systems in Chile, Canada and France. It is a far cry from U.S. healthcare.To live there means someone else making the judgment on what is right for your loved ones. It is easy early in life, quite hard towards the end. You are put to pasture. Your life is lived. We like to fight to the end. Single payer says, no, the pattern is full
Yeah, in the US the doctors will fight for you until your last cent. Of you don't have a cent, they will not move a finger. That's why there is law in the USA that the doctors could not refuse the emergency care to poor, because before the law it was quite often the case.
First of all, Mr. Krugman was contacted by Ms. Warren personally, as was reported by this paper. She wanted him to help promote this approach, of gradual implementation of Medicare for All. Here it is...the Times are officially a political platform for the Democrats.
Secondly, Democratic victories in gubernatorial races does not imply a lack of support for Trump. Montanans, for instance, have elected Democrat Governors in 2004 and every election since. We have voted Republican for President in every one of those elections.
1
It is only a matter of time before our health care system collapses under its own weight. No nation can sustain nearly 25 percent of its GNP on health care with or without its mediocre outcomes. A single payer system is inevitable in time. You can either pull or push a donkey equally without any movement. Runaway premiums, high deductibles, and policy exclusions will spell the end of our catastrophic “health care” system.
1
So basically, Warren is now agreeing to Pete Buttigieg’s plan?
To disagree with the argument here presented by Krugman is to more than shoot onself in the foot. It is to shoot oneself in the face. I am tired of having to coddle the fears of the comfortable. The argument pits those who think their in truth, krappy private insurance protects them when in fact, is but one serious incident away from being cut off from healthcare access.
Those of us who have already experienced full exposure to the worst our current system no patience any more. I have gone decades with scattershot health care, no access to a dentist for over a decade. And forget about any access to mental health care to deal with the slings and arrows of seeing family members die because they don't have access to health care.
Enough already. You with your silly little fears. Do the right thing and vote to support everyone including yourself.
After all, the life you save may be your own.
1
Congratulations Krugman. I didn't think you could successfully walk the tightrope but you did it. For many years you criticized Paul Ryan for being a hypocrite and flimflam man and the press for considering him a policy wonk. Now Warren proposes a healthcare plan that any serious economist considers a scam and instead of critiquing her plan, you focus on phase 1. What cabinet position has she promised you? The hypocrisy runs further and deeper in Washington DC than Paul Ryan! Maybe your readers won't notice but anybody with an economics background will.
1
Reading the comments, it appears the only person who's been paying attention to Pete Buttigieg's health care plan is Elizabeth Warren.
Congratulations Krugman. You've got some steps of your own. I didn't think you could successfully walk the tightrope but you did it. For many years you criticized Paul Ryan for being a hypocrite and flimflam man and the press for considering him a policy wonk. Now Warren proposes a healthcare plan that any serious economist can see doesn't add up and instead of critiquing her plan, you focus on phase 1. It appears you are angling for a cabinet position. The hypocrisy runs further and deeper in Washington DC than Paul Ryan! Maybe your readers won't notice but anybody with an economics background will.
1
Yeah. So?
No president elected is Congress.
Anything through congress will be bit by bit.
So it is all a fake issue.
But hey. What fun is life not without a circular firing squad? So where did Trump come from? Mirror time.
Obamacare cost Democrats 1000 elections. It cost them the House, the Senate and ultimately the Presidency. Even its staunchest defenders now admit it is massively defective.
Why would anyone in their right mind vote to give Democrats another attempt to make things worse?
If Krugman is endorsing Warren he should just come out and state it plainly.
1
I recently spent an hour with a professional ACA consultant courtesy of the local hospital. It took her about that long to tell me "you are better off taking your chances with the emergency room. There is really nothing available for you thats worth what it would cost."
The best she could come up with was $800 a month with a $6,000 deductible. That's to say nothing of all the fine print...
I am better of here in Mexico. At least I can afford to see a doctor here. Still waiting......
obama care fixed a part of a corrupt situation ... government insurance regulators abandoned people who did not work for employers with group plans were being exploited ... the government and the insurers imprisoned people in a unconscionable market ... the issue is clear ... there is still a corrupt situation .... does a citizen of the United States have a right to health care and what is the plan to make that reality ... everything else is about maintaining the status quo ... exploitation of the American people to protect the monies valued by employers, the stock market, and stock holders .... it is necessary to improve our health care infrastructure to meet our needs ... arguing for half measures is not a good thing and not like you to do so
By George they’ve got it. They really got it! Gradual evolution will morph into M4All quickly. I fully guarantee it.
But it must (here in the USA) must start off gradually.
Let’s also not forget about Warren’s two-step after she was called out for misrepresenting her ethnicity. The lefty media has hyped her for weeks but she’s unelectable to the moderate voters in key swing states. That democrats don’t understand this intuitively is surprising.
The perfect is the enemy of the good and guaranteed way to put Trump in the White House for another 4 years.
Medicare for All IS an incremental program set to be phased in over 4 years. Further delay is simply an excuse to kill it and save the health insurance industry. The conversations was successfully changed by healthcare lobbyists as you can clearly see by reading this:
https://theintercept.com/2018/11/20/medicare-for-all-healthcare-industry/
How about (1) implementing Bernie's M4A for seniors (dental, vision, cheaper meds, no need for supplement), (2) simultaneously providing that as a subsidized option under ACA, then (3) making it available as an option under all employer insurance programs. Private insurance would either compete or evaporate.
Dr. Krugman,
I agree. I'm all for "Medicare for All", but I'd prefer it be implemented by Evolution, not Revolution.
Let's improve ACA insurance to the point it competes favorably against private insurance in both care and cost. At that point, the free market will choose the system advocated by Sen. Sanders.
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“What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.”
There are many Americans who react negatively, even angrily, when they “feel” some elites or environmentalists or ... are limiting their rights/freedoms. Take away plastic straws and there will be anger and resentment -protests - that “there go the nature lovers.” Any gun legislation is an attack on freedom to own any weapon a person wants. Always it is seen as an attack on rights, no matter how small or insignificant. Just wait till people must bring their own reusable shopping bags to the store! So, yes, acceptance of a single payer government operated health insurance program with ancillary insurance that might be purchased through private companies will take time. Not only will there be individuals who must see that the government program is less expensive and covers more, but there will be the health care industry protesting the loss of revenue. The health care industry has taken trillions from the elderly. The future wealth of young and old is not as lucrative. We must reduce the amount being spent on health care.
2
@Rev Wayne: People don't understand the side and ripple effects from technological change. For instance, incandescent light bulbs get hot enough to start deadly fires, but LEDs do not. Fire codes should require LED lighting for public safety. It is ludicrous that people cling to dangerous and inefficient lighting because they think climate change is a hoax.
This is incredibly disappointing. I've always thought of Krugman as a smart economist who is a champion of the working and middle classes, but this op-ed proves this is not the case. It is a double disappointment in a week where Elizabeth Warren similarly triangulated away from the issue of M4A. As anyone who lived through Obamacare passage and implementation knows, the new president will get one bite at this apple, and making a "medium-size reform" to the existing Obamacare system will be inadequate to solving the problem, and will take all of their political capital to pass something that will be immediately undermined, sabotaged, repealed, or defunded by Republicans after the midterms.
If this is all the reform we're going to get, why not vote for Biden or Buttigieg instead? What's the point of supporting "progressives" like Warren at all?
The fact Krugman is endorsing this plan is all the evidence we should need to know that no one in the establishment, no matter how much of a champion for the working man they appear to be, is ever going to seriously tackle the problems facing people not wealthy enough to attend Maureen Dowd's swanky Georgetown parties.
1
In the richest most powerful country in the world it is shameful that people are still choosing between medicine and food. It is unbelievable that one illness or one surgery can devastate a families finances for months if not years. Obamacare was a great first step, whether Republicans are willing to acknowledge it or not. Our work is not finished because as we all know Obamacare is still an imperfect solution. Whether Bernie or Warren or a more moderate Biden wins this debate is actually not the issue but rather to continue the discussion in a meaningful way to help the maximum number of people. Since the Republicans have not delivered any credible policy to this day this alone should be a good enough reason to vote for the Democrat.
5
Afraid I dissent from the centerist mode.
The problem is cost. We do not hear much about the cost today- 18% of $20 T is around $3.6T which, since everything is in 10 year frame, is $36T. More than any estimate for Med4All (note: time to rebrand, Medicare has that cachet of geezer). And, given reasonable trend estimates added in, what we have now will be $50T.
I think most America still can be sold: you get way more for much less out of pocket.
FURTHER, since one brings up red states (another aside- WHY do Dems give such weight to South in Primaries? This really messes with things. SC will not vote Dem Prez in my son's lifetime!)- what better thing for M4A than second- class poor- people's care moves up from 2nd class care to full American equal insurance? Would work in South and Midwest well. Dignity does sell.
It may well take years to get the full big step. Only one candidate says so, and really only one will be a bulldog for the full step. Last time only a Romney half step was presented, and we wound up with a baby step...one that is becoming a subsidy actually for the Ins Industry, who will leverage ever increasing subsidy.
Cutting out that middle man and paying directly is the only honest answer.
And we all know what anything less is- CORPORATE.
1
You cannot get a past policy success without fighting for future reform. In your ideal world no politician will ever need to put their careers or campaign contributions on the line because someone in the past will have done it already.
Paul,
I believe you're partially wrong about what Pelosi meant. Yes, you're right about people not appreciating the benefits until it is fully enacted and had time to work, but her critics were right about her saying we wouldn't know what's ACTUALLY in it. As an economist, you know that you can't see what any given policy means right away, and something as complicated as the ACA would have lots of unintended consequences. So Pelosi and Obama knew that it would have to be tweaked and - to use an appropriate metaphor - even have major surgery.
I's a tribute to their vision that it has worked as well as it has considering the Republicans resistance after the 2010 election. A good metaphor for their surgery would be the show, BOTCHED.
@Thucydides: The devils are always in the details, which is why Congress normally delegates discretion to bureaucrats charged with implementing policies, to address unexpected exigencies.
It is perfectly legal and without risk to fund the weakest candidates running for public offices in primaries.
the Patient Protection and Affordable Health Care Act aka ACA aka Obamacare began life as the conservative Republican Party Heritage Foundation free=market capitalist response to the failed Hillarycare Clinton Administration effort at healthcare reform.
Thus there was no public option nor any effective control of the costs of premiums, deductibles, drugs, medical devices, hospitalizations and treatments in America.
How many million Americans have been left without access to affordable quality healthcare as a basic human humble empathetic universal right for the many rather than a powerful privilege for the few?
One-step healthcare reform is already one-step too many far away from protecting too many Americans from bankruptcy, sickness and death.
2
The reality is that Warren make this proposal less than a week ago and for one simple reason: her campaign is losing steam, she is way behind in Iowa and she knows that her proposal for " Medicare for all" is the root of her problem. All of us seniors weren't born yesterday and know that adding 180 million people now or in a couple of years will necessarily reduce our benefits (choice of doctors, co-pays, premium increases that exceed inflation) and those who have employer sponsored plans that pay most or all of their medical plans will be furious. The United States is not Canada or France or England. Improving Obamacare makes good common sense and turning the economy and healthcare upside down because Bernie made a few trips to Canada and Warren decided to join him makes no common sense.
Medicare is wonderful. The best thing about turning 65! We need to work on a plan that makes this available to as many people who want coverage, but also allow those not wanting to switch from their company plans. The goal is to cover as many people without forcing them to do so. The transition will take time and as KY and LA have shown, people like the idea of having health care when it is offered.
2
In short, Mr. Sanders is an ideologist, Ms. Warren is more pragmatist, at least. The “political wisdom,” of the American people, if it exists and despite this “blip” we call Trump, is likely to reward pragmatism, although kudos to Mr. Sanders for keeping progressive enthusiasm alive.
3
The supporters of Bernie Sanders see Warren as little more than Hillary Clinton dressed in a more progressive pantsuit. They decry Warren's plans for healthcare, environmental reform, banking reform, etc. as half measures that serve only her billionaire benefactors.
They are happy to rip apart Warren's healthcare plan as a terrible right wing plan that will sell the middle and lower class out to the highest bidder. Seemingly oblivious to the fact that Bernie Sanders hasn't actually released his full healthcare plan. He's talked about what he wants, but he hasn't shown us the nuts and bolts yet.
In the coming election, Bernie Sanders supporters worry me more than almost any block of GOP voters. The supporters of Senator Sanders went to the polls and voted for 3rd party candidates or even for Trump himself! If Bernie doesn't win the primary i'm worried that his supporters will throw their vote away and in turn help guarantee another 4 years of Trump.
Bernie Sanders is, in my mind, a thoughtful and honest man who will do his best to push this country in the right direction. However, a large number of his supporters would rather set the system on fire than see any other progressive beat him. And that, is very concerning.
4
Yes, I remember that well. That's how Social Security came into being and later, how we managed to get Medicare. Oh, wait, no, that's not what happened. There was an identifiable crisis in each case and the American people saw it, and leaders such as FDR and Lyndon Johnson championed them and they were passed and then became the favorite programs of the majority of Americans.
Sometimes, just once in a while, I wish Professor Krugman had paid as much attention in History Class as in his Economic Studies.
3
Johnson didn’t run on a platform of Medicare in 1964, but rather on the platform of anti-poverty issues (The Great Society) that focused much more on things like welfare. Medicare was there, but it was nowhere near the focus of the campaign. FDR didn’t run on a platform of Social Security in 1932, but on a platform of fixing the Great Depression. Social Security was there, but it was nowhere near the focus of his campaign. (I did pay attention to History, in fact, I taught it in high school.) In either case, the major issue they talked about was a different huge issue than Social Security or Medicare.
Warren has a campaign that has Medicare for All as a component, as a part of a campaign platform that addresses the larger issue of wealth and income inequality. In that way, the comparison to history favors Warren’s approach.
I see a lot of comments that address the 2020 election to articles here. A proportion of them indicate that if Warren runs, they would vote for Trump. And, while a proportion address M4A as the main reason for their decision, the majority of them object to her taxes and economic platform.
The big election is a year away, let’s see how everyone does in the intervening time. I expect a lot can change in each candidate’s platform. Who knows? Perhaps some GOP Senators will even grow a spine and the Democratic candidate will be running against an incumbent named Pence.
While I am an advocate for universal essential disease care for our nation, I won’t willingly vote for a candidate who refuses to allow people to maintain “private” insurance.
Why?
One, because it is dumb (arbitrary and unnecessary). I am unaware of any nation that has universal coverage that found it necessary to do this.
Two, it is dictatorial and I won’t (willingly) vote for a dictator.
And let’s face it, if I am wealthy enough, I can take my body anywhere and pay for “private” care.
Finally, to enforce this, you would have to forbid all clinicians and hospitals in our nation from receiving any payments other than from the government plan. I suspect that would be more than a minor issue.
Needless to say, Senator Warren’s release of a pragmatic plan to move forward promptly through executive actions, while working to get universal disease care coverage legislation in our defective Congress, brightened my day and put her back on the list of candidates I would consider voting for as an independent.
2
@Stephen Rinsler you've put the finger on the one problem with the "single payer" mantra. Most of what you've said is entirely wrong, but that won't stop you from voting as if you actually know what you're talking about, and you're not alone in your dogmatic beliefs. Which, as Paul notes, is the central problem with the all or nothing approach. You'll end up getting nothing.
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Hi Andy,
I appreciate enlightenment.
Please tell me what you perceived to be dogmatic and what I wrote that was “wrong”.
Thanks.
By doing what is doable first, in the next administration, then developing working proposals in a methodical manner in the ensuing time period will have a much better chance of success than throwing out everything we have in one fell swoop. What is proposed is not unlike the development of a new computer program, a phased approach. Introduce the initial phase, beta test. Fix what needs to be fixed, beta test, move to the next phase and so on. I am confident that even Bernie Sanders would agree with the logic of such an approach. I like Bernie Sanders, but get turned off by some of his supporters with their all or nothing attitude.
5
This is the genius of Obama.
He knew that M4A was a non-starter, as was a public option, even with a Democratic Congress; at least in 2009.
What he did, though, was create a set of circumstances that make guaranteed universal health care an inevitability. I don't know what form it will take, or how long, but thanks to Obama and the ACA, I know that this country will someday in the foreseeable future join the rest of the civilized world in ensuring that all citizens can see a doctor without having to worry about bankrupting themselves in the process.
Thanks, Obama!
6
@John Actually, he was told after winning the election, while they were setting up their admin, but Obama and team were told by arepubs that they would not accept anything but the Heritage Foundations RomneyCare as a basis for health care, that single option would not fly, but that Repubs could get behind the ACA...that is until McConnell started his working to make Obama a One Term President (and he is Still trying even today).
Then, after providing 2x as many changes and amendments, most of which did not fly, but still more than twice as many (several poison pills) were put in by the Repubs than were put in by the Dems, who tried to make it a working article. The Repubs then voted en mass against it, in lockstep, against their promise of support.
From then on the Republicans have been the party of NO, No Morals, Mo Spine, No Constitutional duties upheld, their job seems to be nothing more than fundraising, in the Senate, since McConnell allows almost Nothing to reach the floor to be voted on. For the last 10 years he has acted thus.
Do not blame Obama for what happened to the ACA, the Repubs poisoned that well, or tried to, and now want to uproot it entirely.
THAT is not gonna happen.
I'm a Bernie supporter and I believe that Warren is approaching her healthcare plan very shrewdly, which is why she is my top choice. Professor Krugman should stop painting all Bernie supporters with a broad brush as he tends to do.
Most Americans, when given the option, would likely go for a public option. Medicare is the arguably the most successful social program in U.S. history and we already lag most other developed nations in implementation of a nationalized healthcare system that works for all of us.
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I think the difference between aspiration and reality are at work here. While Medicare for all is perhaps the best system to get health care to everyone it is a long way from where we are now. So the question is how to get from here to there. Warren has a realistic path we might take in 3 years , more likely longer, but in the interim will get more insured and people used to the way a single payer system would work. Bernie is like the those on the right "my way or the highway" -- who can work with someone like that ? It is why he has never actually gotten much done . On the other hand Warren has shown how to build and run the consumer protection agency how to work with other in congress and how to confront the horror of the republicans with carefully reasoned arguments and the weeping billionaires with the disdain and humor they deserve.
3
My husband and I have been on Medicare since we became eligible. It was actually a condition of our retirement health benefits. Even people who don't have retirement benefits, and for whom it is a stretch, tend to acquire private insurance to cover the significant gaps left by Medicare coverage. According to a source I found on the web, two thirds of Medicare recipients also have private insurance.
Given this, I'm not sure Medicare for All will be all that popular with current Medicare recipients. A public option seems more doable at the start. It has the added benefit of being a point of comparison for those in the market for private insurance.
2
@Suzi I really don't understand the attitude that "you can't have any this is mine." It's really sad that this is the way the elderly in this country think about their children and grandchildren that we have to suffer in debt and poverty without insurance while you reap all the benefits the country has to offer and share absolutely nothing.
The problem of an incremental approach to " health care for all " is that it is not really "health care for all" it is rather "health care for all but the left out ! The problem of american health care is that it is dominated by corporations that run huge hospital systems, huge pharmaceutical systems and private insurance companies that have the power to counter any proposed incremental changes that may injure their bottom lines.
These corporations do not see as their mission the providing of health care to all americans but rather how to exploit the current system in order to extract the maximum of profits. Any governmentally initiated health care system that seeks to provide for "health care for all" will have to have a plan in advance of how they will respond to the inevitable resistance that Hospital systems, insurance companies and pharmaceutical companies will react with. The goal of providing health care for all incrementally is not enough if it has no plan in place to counter the Hospital/pharmaceutical/ insurance complex.
Incremental reforms to health care also create the problem of funding and resistance to taxes that unfortunately become the center of attention in elections when the economy is doing relatively well but people still feel over taxed. Sanders and Warren both need to make the american public aware where the opposition to health care comes from and the changes that must be made not incrementally ...but now!
1
I assist a man with medicaid with some serious medical challenges and every step has been a breeze.
For me however to get my colonoscopy recommended screening coded and billed correctly has been a nightmare. I think misbilling (in my case for $4,000) should come with financial penalities. I do wonder if some folks would simply not do their due diligence and take personal responsibility for this bill which is not their responsibility, as a recommended once-a-decade screening. I am so happy I spent days getting documented agreement from the provider and insurer before the procedure that it would be covered 100%. It still hasn't been, and it's still a nightmare, but at least I have documentation I can point to!
1
@northeast
Yes, My "free" colonoscopy cost me $1,400.
The procedure was free but the anesthesiologist (and insurance company) hit me for the $1,400.
@Steve of Brooklyn
Wow, you didn't fight it?
Candidates advocating switching cold turkey to single payer all at once are not electable. There is simply still too much resistance by otherwise progressive voters and centrist independents wanting to keep a private option to get it done in the near future. Democrats should not let this issue destroy their primary goal of getting rid of Trump. Compromise is not evil. AOC and other firebrands with huge Twitter accounts need to get a grip. They are not going to remake the US in a single year!
4
"Single payer" is not a goal. It's a means to a goal which is "universal" health care. I'm surprised you, as an economist, would use such a shortcut, even if it's simpler for you to get your message across.
Yes, single payer does provide some advantages. Canada and the UK have "single payer". But it also has its own disadvantages. France and especially Germany have "universal" health care with mixed public and private funding, and they do health care better than the first two (I can attest personally that France does it better than Canada).
Single payer is no panacea, and doesn't do the job any better than mixed public and private funding. Yes, even with private insurance companies. Universal health care is more easily done in increments, too, than single payer, from America's starting point. So it's lot easier to achieve universal than single payer because :
1. it's not a one size fits all solution that Americans hate (at least those who already have cover, which is a lot of voters
2. it doesn't make mortal enemies of the insurance and health provider industries, which together with pharma represent 1/6th of the US economy. that's a lot of lobbying power to get around.
So please, Paul, now you have to stop using the magic words "single payer" and educate your readers on a new word used everywhere else : "universal health care".
Awaiting your amended vocabulary...
4
What many voters may not realize is, Medicare, in its current iteration, is an amalgam of government- and private insurance-provided coverage. This is just a guess on my part, but the percentage of those on Medicare who rely solely on the federal insurance plan, which covers hospitalization and little else, is probably in the low single digits. Most of us purchase supplemental insurance to cover office visits, out-patient medical care (day surgeries, etc.) and home health services from private insurance providers. There are also millions whose "Medicare" is provided 100% by private insurers, the so-called "Medicare Advantage" plans, where Medicare pays the insurance company a set amount and the insurer then tries to keep their costs down and profits up in the usual fashion. This is why the the "advantage" is not always in the favor of the patient.
As a matter of fact, over time, private insurers pull in much more money on these supplemental plans than Medicare recipients pay in to Medicare in the form of monthly premiums which are deducted from one's Social Security check. At that, the cost for Medicare, when everything from taxes paid during one's work career to premiums for both federally provided and private company provided insurance is still much less than private insurance alone.
A phase-in plan is imminently better than an abrupt elimination of private insurers and, truth be told, we will probably still have the AETNA's and CIGNA's around for decades to come.
Years ago, we could have slowly expanded Medicare from both ends (birth-5, 55-64), waited a couple of years to see the results, and then made changes. If we had, we would be very close to Medicare for All now. We actually could still do this, but we've lost a couple of decades.
Incremental isn't sexy, but if one is making significant steps over time, it sure beats purity, defeat, and no changes.
3
Warren had months to determine how to address the health care issue. She took a position in full support of Medicare for All, managing to morph the Democrats most favorable issue into a liability.
Three weeks later, she had to back off that position, as her poll status began cratering. Three people on barstools could have seen that one coming.
The decision to force feed MFA on the public decidedly against it, especially in MI PA and WI, is a stark example of extremely poor political judgement.
We cannot afford to lose to Trump in 2020. The GOP has written laws and packed the courts with conservative judges long enough, while we yell at people in restaurants....yet Warren chose to cling to a losing, idealistic, never-could-possibly-be-enacted political plank.
I don't think heaping praise on Warren for how she handled this issue serves Democrats well. Her candidacy is about the only chance the GOP has to win the Presidency next year.
2
Hmmm, incremental improvement and evolution . . . isn't that the oldest, most-organic story of Life on Earth? Sure seems like that would likely work. -C
3
Medium sized reforms mean we will be struggling with public healthcare issues for the rest of our lives - 2 steps foward, 1 step back, Repub defunding, healthcare industry machinations, etc. Instead, lets take our best shot at fixing it realizing we may have to adapt. To drag it out is crazy - fix it.
Gee. Kinda like our founding fathers kicking the can[non] down the road and hence deciding against not pinning the slavery problem on George III's crown -- alongside our other grievances on taxation w/o representation -- when drafting our Declaration of Independence. Let's hope single-payer healthcare doesn't eventually require having to AGAIN spare hundreds of thousands from having died in vain.
But the blueprint, like our Constitution's Preamble, withstands the test of time. That success at least preconditions perpetual perfection is certainly of the very order whence more perfect unions best form when MOVING FORWARD. After all, our founders never said: MAKE AMERICA MAY-FLOWERY AGAIN. Nor was "perfection" ever definitively predetermined.
1
The article talks about Medicare for all vs private insurane, but as a recent Medicare enrollee this confuses me. Medicare covers only part of my health care costs - I still need a supplemental plan, provided by a private insurer, to cover the rest. When people talk about Medicare for all, are they also proposing an expansion of what Medicare covers, to eliminate the need for an insurance supplement? I have not see this part addressed.
3
Very good question, Wonderdog.
I have not seen this at all. I pay $100 (Medicare), $200 (supplement), $50 (supplemental drug), $50 (dental) I still have out of pocket costs for glasses, hearing aids, & Long Term Care insurance. What are they doing for us? How will we be affected with one payer or M4A?
1
My fear is that the Bernie-or-bust people will be spoilers like the Naderites. They don't really care if they lose, and draw enough votes from the Democratic nominee to get Trump reelected, as long as they get to believe they're RIGHT.
1
Absolutely agree! I was dismayed Bernie was running again. I thought he was too old and angry last time! I blame him as part of the reason Hillary lost.
Unless the Senate flips, virtually none of the Dems plans will come to fruition. Their promises are made of political fairy dust.
2
Have you read Warren’s proposals linked in Dr. K’s article? She identifies several steps she can take via executive action. You know, like Trump, only in reverse.
4
As a precursor to a “multi-step” process all current government run (FEHB, SCIP, DOD Tricare, Tricare for Life, VHA and IHS) programs should be migrated first. The Federal Government already has the authority to negotiate on behalf of all these insurance programs.
Once these programs are successfully migrated then open it up to a Medicare option for over 50.
If and only if all these programs are successfully migrated with price policies that are sustainable for both consumers and the healthcare industrial complex should Medicare for All be contemplated.
Insurance is full of counter-intuitive traps. The big difference between M4A and M4All Who Want It is that in the latter model, Medicare will have to compete for providers. They don't have to do that now, because most providers are willing to treat elderly and disabled patients for Medicare rates.
But will they be willing to treat EVERYONE for those rates? Will the transitional version allow providers to treat the elderly at Medicare rates but decline to treat younger patients at those rates? If not, the elderly may actually LOSE access to some providers who can no longer afford to serve them.
The struggle over reimbursement rates remains the dirty little secret of the M4A battle. The transition method brings this issue into focus. We'll know the Dems are serious about their proposals when they start discussing it.
1
Please try to understand the Bernie supporters who want M4A. I spent my late teens and early 20's without health insurance. I was terrified of ever getting sick. I also have spent a good portion of my life working in medicine, so I have an up close view of healthcare. I've watched it get worse year by year. It is sad to see how bad a job we do covering people and how hard it is to get decent health insurance. The need to change health insurance didn't just start 5 years ago, or 20 years ago. it has been an issue all of my adult life and we are still talking about doing something. I'm doing better in my life, but the last 40 years of wishing and hoping for something better has warn me out. I'm done with wishing and hoping incremental change will get us across the goal line.
161
@Mark
Unfortunately, as is usual the far left (of whom Bernie is the true embodiment) would rather have nothing than not enough. In fact because of Obamacare and a general expansion of Medicaid and Medicare there has been a steady increase in the amount of healthcare coverage in this country over the last 40 years
18
@Mark: I was in the same status as you when my impacted wisdom teeth had to be extracted. This was before the insurance industry took over health care. I shopped around and found a reputable dentist who did it under nitrous oxide and novocaine anesthesia in his office for $200. This was in 1980.
The paperwork overhead for such an operation today costs far more than $200, because the insurance industry runs health care in the US now.
16
@John: Bernie is stoked and stroked with Republican money almost as much as Trump is.
Healthcare is easy to fix.
Instead of campaigning to voters - ie employees, Democrats should campaign to employers.
Offer employers the opportunity to buy into Medicare. Fix the cost at whatever the employer is paying today and guarantee annual increases at the level of inflation for 5 years.
Small employers in particular will jump at the chance to offload their health insurance obligations in double time.
Small companies with < 200 employee should be offered first in. Health insurance is a completely unmanageable burden for these small companies, where a large cancer claim, or a premature birth claim can increase the annual premiums by 30% or more. Take away that risk and the change will happen. Slow at first and then a snowball effect as people see that coverage is good and cost is contained.
The economic boost to small companies would be huge. Managing healthcare insurance takes time and is usually fruitless. Let business owners use that time to grow their businesses.
6
All I want is the ability to buy into MediCare. Once that is possible, we will be on the way to universal health care. Remove the requirement that employers are required to provide insurance, then Americans will have the choice of getting private health care insurance on their own, or join the MediCare crowd.
52
@catlover
Those Americans do have private health care insurance from their employer. Why would you advocate for taking health care insurance away from people?
1
@dlb Until their employer no longer provides it (the number grows every year), or the options they offer are so inadequate the insurance is not worth the premiums. That is where we are headed.
17
Oh. Let businesses off the hook, in exchange for nothing. Good thinking.
Private insurance is more then happy collecting premiums from the young and healthy while turning a tidy profit and leave the government holding the bag covering seniors, the people that use healthcare the most, cost effectively I might add.
Imagine what Medicare could provide with the entire insurance pool of every American.
236
@mlb4ever
Medicare and the people who use it are far from cost effective.
5
@Driven: I think you don't understand risk pools. If all those younger, healthier people were added to the Medicare risk pool, paying premiums, it would cost the Treasury less per person.
18
@Driven ironically you've hit the nail on the head, but probably not in the way you think. If you know what you're talking about, you'll understand that medicare is an order of magnitude more cost effective than private insurance (admin costs 6% as percentage of total costs versus up to 30% because private insurance includes ... profit). But patients cost more because they're the ones private insurance rejects.
Beware saying the right things for the wrong reasons.
12
As usual for my hero Paul, You hit the nail on the head with your assessment. I was a bigger fan of Warren before she announced her Mandatory Medicare plan & I hope that walking it back this far helps her potential candidacy.
5
Professor Krugman. Enough with incrementalism. People are dying and going bankrupt now. I'm for starting with the full Bernie and compromise from there. His implementation is incremental - 10 years at a time. If Republicans fear the people are behind it, they'll give more than we ever thought possible.
If we start with the full Biden, we'll be lucky to get a rule change, because I don't believe for a minute that the Rs will have an "epiphany" when Biden's elected and rush up to compromise, as Uncle Joe has suggested. Didn't happen with Obama when Biden was VP. Can't imagine why he believes it will happen now.
I'm on medicare. Can't wait until my wife is. Easiest, best insurance we've ever had, not having our employer change companies, not having to find new doctors and pay high deductibles and co-pays and not having to argue with the insurance company about why things weren't covered. Serious heart surgery, broken ankle, broken hip, all at different times while on Medicare - walked out of the hospital with a signature and not a penny owed.
Anything short of that, which is achievable for everyone, is selling people short at the expense of insurance and drug company profits.
251
@allseriousnessaside
While I am a big advocate for Medicare, I don’t think people are “dying” because they are on private insurance or Medicaid.
The bankruptcy part I agree with.
11
@Joe I would beg to differ. If you have a $5k annual deductible, or even $2k, you might not be doing the doctor visits that signal a serious problem. And, of course, you're forgetting all the people that aren't covered. And drug prices mean people aren't taking them or cutting dosages.
56
@Joe actually people do die all the time for having the wrong insurance or the wrong geography/timing.....sure if you are bleeding to death pressure will be applied to stop the bleeding but don't expect insurance to be in a hurry to cut out the underlying source of the bleeding. The insurance companies don't put reality on their billboards they pay for with the money saved when their customers die or get thrown off the plan when they get too ill to work for their employer-sponsored plan and can no longer afford cobra. I'm glad you and those around you have been fortunate so far. Real people actually do die for things as dumb as trying to drive themselves to the correct health-insurance-affiliated urgent care while having an active heart attack. Of course I don't see people actually "dying" like this every month, just as often as not. Health insurance (including medicare) does not equal health care, but you are a lot more likely to get the care with the medicare than with a lot of other options.
32
"voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.
It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion."
Obamacare is as much (or more) vilified on the Right as it is glorified on the Left. Yes, there are aspects of ACA (specifically, Medicaid expansion, pre-existing conditions, and keeping kids on parents' plans until they are 26) which have been accepted as "successful". However, ACA failed simply because it did not accept that in the short- or long-run, the private insurance complex has to be demolished; in fact, it was a solution built around private insurance. That was wrong then; it is wrong now.
@anatlanta
Obamacare saves an additional half a million American lives a decade.
If you call that "failing", imho your definition of "success" is too cynical to be useful ...
The very purpose of Obamacare was to insure 20 million people more, knowing that Congress had tried to do so for DECADES, and that waiting one more decade until there would finally be a coalition in Congress that can pass a bill that immediately insured 40 million instead of 20 million uninsured Americans, was just immoral and as a consequence, no longer an option.
From the very beginning, the Democrats had plans ready to built on the ACA, which merely lay the foundation. A public option was one of them, and thanks to Obama's year-long campaigning on it, a majority of the American people now support it too.
The reason why it's still not signed into law is not only because of the GOP's fake news. It's also because part of the left shamefully abandoned Obama because they wanted universal HC overnight, even though the votes weren't there AT ALL.
And the votes weren't there because swing states WANTED private sector based reform.
Conclusion: the problem with part of the left is that they're anti-democratic. Forget about public debates where we as citizens first have to convince our fellow citizens of our idea(l)s. A president should ONLY represent ME, and if he doesn't, he must be a bad guy.
That's NOT how change has ever been obtained ...
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Let's be clear. Medicare does NOT cover the cost of care. Hospitals make up the difference with higher reimbursements from patients with private insurance which means higher premiums for those patients. So the term Medicare for all is misleading.
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@Kathleen
Hospital chargemaster price sheets are essentially made-up documents - they don't represent actual cost to the hospital for a service. Instead, they represent what the hospital wants to be paid for the service. For people without the price protections of an insurance policy, charges are frequently through the roof - far above costs, while for those with Medicare or insurance, prices are presumably closer to costs. But we don't know what those actual costs are, so we can't tell to what extent, if any, hospitals shift legitimate costs from Medicare to private insurers.
A comprehensive new health care policy, to be sustainable, would need to include effective price controls that would make the chargemasters reflect actual costs.
Being able to receive medical care when and where we need it rather than waiting until we can afford it is awful. Having good health is part of the pursuit of happiness. It's part of being able to contribute to society, to work, to earn a decent living, to have a decent life until it's time to die. Medicare for all is not about miracle drugs, having a Lexus instead of a Corolla. It's about making it possible for all working Americans and legal immigrants to stop fearing financial ruin when they or a family member requires ongoing medical care. It's about eliminating the claim denials that are part of the system. It's about making more medications less costly. It's about being able to see the doctor of our choice rather than the ones the health insurance companies decide we can see.
Everything about our current system works against going for a checkup, seeing the doctor when we're ill enough to have to stay home for 3 days, or when we suspect something is seriously wrong. We need to sever the tie between employment being covered for health care. The ACA was a step in the right direction. But if this country doesn't take some more steps we're going wind up at the beginning again.
As of now we do not have a health care system. We have a well funded wealth care system that is not functioning for us but does remarkably well at seeing to its own needs.
11/18/2019 8:13pm first submit
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@hen3ry I meant to say that Being able to receive medical care when and where we need it rather than waiting until we can afford it would be great. It's awful that we can't.
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@Rima Regas and Hen3ry
This is axactly why I am debationg whether to buy health insurance for 2019. I haven't used my health insurance in two years, partly because of surprise charges. And if I did need to use insurance in 2020, how could I prevent out of network provider charges if I had to go to a hospital. I mostly think it makes more sense to invest what I would spend on premiums.
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@Gem
That might work as long as you don't get cancer or suffer a stroke or some other dread disease that requires a lot of hospitalization and/or expensive drugs. This is the point of insurance--you can't always know what will happen with your health and you need protection for catastrophic events beyond your control.
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If necessary for a transition, I would be happy with a buy-in Medicare plan. I would definitely buy into the system. As more people do, the private insurance market would quickly fade away. I don’t care how we get there, but the transition needs to start.
7
I’m tired of the insurance companies. I pay $6,000 a year for health insurance and have a high deductible. After suffering some health problems recently, I have gotten stuck with thousands of dollars of bills. The only thing the insurance has done is give me a “discount” from the inflated rates the insurer negotiates with providers. I’m sick of the system. I’m ready for Medicare for all and would be more than happy to pay my annual insurance premiums into Medicare in exchange for real coverage.
767
@Jon S And you won't even have to pay your annual insurance payments or anything else according to Bernie's plan. It will cost you half as much as you pay now or even much less in taxes and dental and vision are covered and you can never be kicked off there is no cap. Go to Bernie's website and see the plan.
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@cheerful dramatist And how many votes will Bernie's plan carry in the US Senate? Not enough to pass, even if 2020 is a wave election. Ask senate candidates in the states that will be hardest to move from red to blue if they want to campaign on Medicare for All. I bet there is not a single one who has a chance of winning that will campaign on Medicare for All. I have yet to hear how Medicare for All passes the senate after the 2020 election, even if Bernie is elected President. Wishful thinking won't achieve universal health insurance coverage. Ask Ted Kennedy who passed up a pretty good health insurance plan Nixon proposed because he wanted single payer. He later said it was the single biggest mistake of his career in the senate.
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@Jon S Thank you, yes. I'm Canadian/dual citizen and I've been waiting since 1980 for the U.S. to join the civilized world with single-payer. Apparently the American voter loves medical bankruptcy.
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I’m so relieved that Warren has adopted the two step approach. With Medicare for All-who-choose-it the corporate healthcare companies will have to compete to hold onto their customers. Sounds like the American way to me. ‘We the people’ decide to stand together to force corporate vultures and their paid-for politicals to behave themselves through the language they understand ...the marketplace.
4
@HG
Thank You, HG for saying what I was thinking,,,
1
To make it all fair, how about you do without health insurance until the incremental change is complete?
This is probably right for another reason. Once public health insurance proves itself viable, employers will increasing seek to reduce their costs by removing health insurance as an employment benefit. Workers won't resist in the knowledge that the public option works. A gradual evolution towards national health insurance makes sense.
7
The ACA solved some of the problems. An adult daughter has good insurance for less than $100 a month. A family with a couple and 3 small children $2K a month so we have a ways to go.
Hit my head recently and spent 24 hours in the hospital. Stitches no surgery $40K. Insurance and MC covered it but, if I didn't have insurance through my wife's employer I would have been stuck for a healthy bill.
Improve the ACA but open medicare to all. Leave insurance companies in the mix: Seems like a consensus could be built this way. The alternative: GOP defunds Medicare to the point where it is worthless, and SS as well.
Bernie's all or nothing approach will simply work in the GOP's favor during the election: Reelect Trump it could be said. Bernie nuts threaten to not vote if Bernie is not the candidate or to vote for Trump so there you have it. Bernie appears to be working on behalf of Trump.
God help us.
7
Having recently returned to the US from a long residence in Europe, I am astonished and disgusted at the mess of the US healthcare system. In a single-payer system, it is far less expensive (1/3 to 1/2 the cost) and, in covering everyone, its results are 100% better in epidemiological terms. Here, just to enter the insurance system, I am now wending my way through a bureaucratic maze so daunting and confusing that - with private vendors calling me incessantly and the "full mailboxes" of "navigators" - I feel helpless and incompetent. Most Americans have little idea how dysfunctional their healthcare system is, how wasteful, how unnecessary its complications, and how simple the solutions can be. Sure, there are many problems in the European system, but it is nothing in comparison to this.
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Sorry but your numbers don't add up. Please cite something, anything to back up the costs including taxes paid and outcomes especially.
@rjkrawf
RJ, We know how bad it is!!! We're just insecure about the best path from where we are to a better system. We don't want to jump the gun & mess it up (eg. Brexit, no Brexit.)
@Rocko, in fact those are official statistics that are frequently cited. The 1/3 cost is per capita. That means the US actually pays more per capita in taxes for worse outcomes. The big differences are that 1) doctors are educated essentially for free tuition and so don't need to get high salaries in order to pay off massive debts; 2) drug treatments are generic; 3) it can, but does not necessarily, take longer to get some services as there is some rationing. All in all, outside of boutique treatments for rare illnesses, the US system is the worst in the industrialized west BECAUSE it isn't socialized.
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Whether the Warren "two-step" will get her the nomination and the presidency is still in doubt. For this progressive Democrat the two-step I favor would be: (1) implement the Medicare for All plan on those already receiving public health care insurance through Medicare (44 million) and Medicaid (74 million), and (2) once the the inevitable bugs are worked out, offer it through a "public option" on the state insurance exchanges. Two big advantages of this approach are that federalizing Medicaid would immediately allow people in Mississippi and other such states to receive it. Second, it is consistent with consumer choice under free-market capitalism and will eliminate the attacks of "socialism" by Republicans, the for-profit health insurance industry and hospital and physicians associations which fear the low reimbursement rates for Medicare would put them out of business.
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I applaud Warren for having the political courage to admit that she misunderstood the peoples ability to understand Medicare for all. American spend 33% of it total budget for war and 17% on healthcare. In America when you go to the hospital the first thing they do is x ray your wallet. Medicare works and its cost are affordable rather than bankruptcy for a health issue
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@Sean Daly Ferris
Perhaps we could agree to cap the total war budget at 17%, and raise the healthcare budget to 33%. The US population would receive a better return on their tax investments.
@Sean Daly Ferris What you're applauding is a politician sticking her finger in the air. She looks more and more like Hillary every day, which is to say she's unrecognizable because no one can keep track of her changing stances.
@Ross its past performance that I admire
All this abstract talk is great but have you ever worked a call center and listened to women crying and hoping they can become pregnant again so they can go back on Medicaid because even with a very substantial subsidy of say $700/month they still find healthcare unaffordable? Have you talked to people who are planning to quit their jobs because they fall in the Medicaid ACA gap and so will add to the cost without helping to cover that same cost. I can cite many more examples of similar behavior. Healthcare now, for everyone, no excuses.
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@Nick
Right, Nick. As Bernie says, take away a little from a good program pretty soon the other side will be arguing to take away more. Healthcare now, for everyone, no excuses.
Sorry but your anecdotal experience doesn't trump actual data and stuff. The numbers don't support your thesis.
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@Nick
What if your approach gives "the Donald" four more years to torture the woman in your example & the rest of us & the environment & our allies. The dreaded unintended consequences might be real.
Why be incrementalist when we KNOW what Will work, based on other Nations. Will some fatcats lose their cushy job of being literal death panels, or can we get to a real, single payer without middlemen taking 40% of the pie for their own admin?
All doing incremental change does is allow the ones abusing the system to morph into something that might be harder to find, better to remove insurance companies entirely even though it will mean early retirement for a large number of medical billers and Insurance staff, but they do not get the real money anyways, and just drive up the doctor fee cause he has to pay them to sort thru billing codes, two or three times per bill.
Better to clean house and start with something intentionally built with NO Loopholes to it, so there is no way to game it.
THEN the people will be getting what they pay for in medical care, not 'insurance' that merely makes sure you never see your money again, no matter what.
So lets drop the incrementalist approach, it is slimy anyhow.
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I had a little heart flutter recently and spent two nights in the hospital mostly for observation. No surgery or other complication was involved. The bill came to $46,000.00. The cost and availability of medical care is a huge problem in this country and the only institution that can do anything about it is the government. I keep wondering why it is that all the other advanced countries in the world can afford universal health care but the United States can't. Maybe the Republicans think it is socialistic.
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@Clark Landrum
Right, Clark. ANYTHING that's good for the people and not for the wealthy is called socialistic. It's time to change that, and Paul, with his convoluted argument is no help.
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Disagree - PK has it exactly right. Polling on the ACA shows exactly why incremental change gets you elected and shows people the benefits, allowing for more change. Improving access to healthcare is a process, not an event. And what the people who are howling for Medicare for all don't mention is the reality of limited services, donut holes, medication costs etc that all come with Medicare. Medicare for all is a loser in the general election. And Col. Sanders is not a democrat.
Many Doctors are refusing to accept Medicare because the overhead and unrealistic payment structure makes it "just not worth it". Government run healthcare like the VA is always inferior, inefficient and too costly. The entire healthcare problem is that it is the only industry where nobody asks " what will this cost" and there is no ability to shop around. Now , with the new law, medical costs must be posted and intelligent consumers should be able to shop around and let competition take care of bringing down costs. Government run healthcare is government in the drivers seat of what treatments you get, who gets it, and where you get it. This kind of power in the hands of government is extremely dangerous when some bureaucrats decide they are going to use the power "for the good of society". We already had enough of this government bureaucrat superiority with the "Russian collusion" fraud. These people are dangerous and their desire for power knows no bounds.
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@James
Except that all over the world and here at home, government health programs are far less costly than the bloated, redundant private system. And the nature of medical care is that "shopping" for a good price is often not possible. Try doing that in the middle of the night when you've just discovered that your intestines are blocked with a tumor, as I did.
@James
Yoo-Hoo ! Every major industrial country has it and loves it.
@James Will you have the ability to “shop around “ for the best choice (in price) if you are rushed to the hospital while unconscious?
The truth of the power of incrementalism is known to anyone who has been a parent or the owner of a dog.
Children and dogs all test limits and parents/owners all use behavioral tools to channel and minimize these excursions. When we "catch" a child quietly playing or a dog understanding the house is not a proper toilet, we lavish praise on them and often find subsequent lessons to be even easier.
Skillful politicians understand the power of a handshake or a selfie and the most skillful have learned how improving health care for the constituents rebounds to their electoral benefit.
Hardly anyone would skydive without antecedent ground training, an understanding of who packed their parachute and at least one tandem jump. In just such a way, people will not abandon private insurance without first seeing the full scope of the new coverage and seeing how others have made the leap successfully.
For a few intrepid souls, it's "Geronimo!" as they leap into unknown health care coverage. The rest of us must start by jumping off the curb of the sidewalk.
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Incrementalism only applies when human beings are unnecessarily suffering and dying.
When Wall Street want a $1 trillion bailout or some cowardly cowboy wants to look presidential by killing people in the Middle East, it’s always full speed ahead.
If and when "Medicare for all" gets implemented, private insurance companies will essentially die. Yes there will be some buyers for Part D or for cadillac plans or supplemental insurance but that business will be miniscule compared with what they do today. That is the elephant in the room and Americans (of all stripes) have to understand what that means to them before they will accept it. Yes, the insurance lobby and the greedy politicians will fight hard to avoid or avert the change, but if the public wants it, it cannot be stopped. The pain inflicted by our current system has become widespread and acute, and it is getting acute.
The two-step is necessary for two reasons - first, the changeover from the current private insurance based system to Medicare for all cannot be implemented overnight anyway; second, the first step is necessary to educate people on what it will mean for them and how it will reduce the pain which the current system is inflicting
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No health care system will work in this country without drastic cuts in costs. Other national systems have taken steps to make health care much less expensive. Our system has been privatized for so long that it will be difficult to overcome the strong lobbying efforts by interested parties to keep the system to their liking. Pharmaceutical companies,insurance companies and hospitals will have to charge their business models in any new system and will spend millions to try to avoid this. Candidates need to educate on why costs are so high and give proposals on how to reduce them.
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@Viincent
In the US pricey innovative medical treatment and medicines are the goal of pharma and others. It's no accident that we are currently in a crisis in cancer treatment and other areas due to lack of production of tried-and-true medicines that are no longer in patent and thus not able to charge exorbitant prices. (The gov's rec? Raise the prices on these to make them competitive!)
What we need and other countries have is government bidding for medicines and holding ALL prices down.
The risk of an incremental plan is that what we'll see is the costs of insurance going up without costs of care going down, and there will be no appetite for the next step. Single payer is the way to bring insurance costs down, by reducing administrative costs. And no one will miss having to figure out which private plan is best for them.
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@Georges Kaufman There is no government run plan that has ever brought costs down in the history of the world. The opposite must be done where prices are posted, real competition is encouraged and the free enterprise system forces prices down. What did LASIK surgery cost when introduced, and what does it cost now? The problem now is that nobody knows or even asks what something costs so there is no way to shop around.
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A public option, the option to opt in to a kind of Medicare, should be easy enough to pass with a Democratic majority. It should be painless for those who have private plans. If successful most people will adopt it.
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Taking some time to complete the transition from private health insurance to single payer has the additional advantage of giving the supply side of healthcare a chance to ramp up to meet what will certainly be an increase in demand for services of all kinds. And it will give the health insurance industry time to find other ways to make money. We are not only going to need more healthcare professionals, we are going to need a different kind of healthcare professional, the kind often found at teaching hospitals, who accept limitations on their income in order to be part of something good.
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@Billy Glad Why does Toronto have 176 unemployed doctors while patients wait for care? Because the only way to control costs in a socialized medicine system is to ration care. Government run operations require a budget approved by Congress each year and when the demand exceeds the budget, care is rationed. This always results in government deciding who really needs care and who can wait or is simply not treated. No, a better answer is to make doctors and hospitals compete for business and post all prices for services instead of this system where nobody asks what anything costs and their attitude is always, " my insurance will pay so I don't care".
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@James - When it comes to access to healthcare, someone else is always making decisions for you in this country. All providers don't take all private insurances, so that impacts choice. Insurance companies determine how much coverage you can get for what care, so that impacts choice. Employers who sponsor health insurance for their employees make decisions about the cost to the employee and what gets covered, so that impacts choice. Providers tend to practice in places they choose to live, so that impacts choice. Pharmeceutical companies and medical equipment manufacturors make decisons about what to produce and what to charge and that impacts choice. All these decisions are made by faceless corporate bureaucrats and driven by the desire to maximize profit. Providers have to accept the reimbursement rates offered by the insurance companies they accept. The question each insured person has to ask is will all those participating in my care accept my insurance's reimbursement amount as full payment for my care. Posting prices is irrelevant to that discussion. For the uninsured, only the very wealthy can participate in our healthcare system beyond the most rudimentary doctor office or emergency room visit so price schedules are of limited value to that population as well. We have a complex, disjointed and profit driven healthcare system in this country. Posting prices, while not a bad idea, won't fix much.
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@James Small quibble. Canada, nor any other country, has a Congress.
I was glad to see Warren modify her position. If Bloomberg enters the race, he most surely will develop a position on how we are going to control costs. He has the "tech" savvy after all. Guaranteed health care for all does not work any other way. Medicare is headed for insolvency faster than Social Security at this point. Let's remember that there are two sides to the equation, as well as higher taxes on the wealthiest among us.
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@USNA73,
Social Security can easily be made solvent for another century or longer by tweaking the level of taxable income or the FICA tax rate or both. The only impediment is that half of the political class, the Republican half, would prefer to kill the program entirely in favor of the sharks on Wall Street.
Medicare costs are comparatively inexpensive for similar coverage which the profit-seekers in healthcare see as a threat. They want Medicare to disappear too, and the Republicans, always eager to go where money leads them, are happy to oblige.
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@Purple Patriot Today, Medicare expenses are approaching about 4 percent of Gross Domestic Product. Under current law, the Trustees project it will increase to about 6 percent in two decades, then level off.
Unlikely.
But that forecast is built on several key assumptions that are unlikely to occur. In the 2010 Affordable Care Act, Congress adopted a package of cost-cutting measures. In 2015, in a law called the Medicare Access and CHIP Reauthorization Act (MACRA), it began to change the way Medicare pays physicians, shifting from a system that pays by volume to one that is intended to pay for quality. As part of the transition, MACRA increased payments to doctors until 2025.
But what if key ACA cost-cutting measures never take effect, the transition to the new physician payment system is delayed, and the temporary doctor payments continue indefinitely? In that case, the trustees forecast Medicare costs will not flatten out in the mid-2030s, and instead keep rising—to 8 percent of GDP by 2070 and 9 percent of the entire economy by 2090.
As policy goals collide with real world politics, this is a winning perspective, and an honest one. We don’t really know how to get where we want to go, but let’s take a prudent first step and level with voters along the way. We don’t need to promise the world to voters, but we need to get moving in the right direction one step at a time.
Good column!
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I agree that healthcare will be and should be a major issue in the 2020 election. What Democrats must remember is that past elections have shown that many voters don't like drastic change. Putting it another way, Democrats must avoid policies that will allow Trump to brand the Democratic nominee as a socialist. Trump and other Republicans will surely do that, and if Democrats do have a far-left plan like Medicare for All which eliminates private health insurance, the label of socialist Democrat will stick. Keep in mind that the first goal is to win the election.
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I like Warren a lot and would vote for her if I thought she could win. But unfortunately she hitched her wagon to Medicare for All, which might or might not be viable if enacted, however I think will kill her chances of being elected. Too many voters just don't want anybody messing with their private insurance. The better approach which would be palatable to most would be to offer a public option allowing people to sign up for Medicare if this wish. Over time I think more and more people would see the benefit of that and eventually Medicare for All might be acceptable to the masses. Until then, its more important to get Trump out of office, and I think Warren and Sanders have made that impossible for themselves.
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@flaind
But, she has modified her plan to easing into a new healthcare regime after a three year buildup of publicity and examples. No candidate will change congressional-mandated policy immediately in any event. Even Trump and the GOP failed and still were punished for attempting to kill our current healthcare system, ACA. Sen. Warren is in favor of saving the ACA and also for improving Healthcare for all Americans. And you can help her do just that.
Good topic, but Mr. Krugman has did not mention that 70% of the American people already favor "Medicare for All."
https://thehill.com/hilltv/what-americas-thinking/412545-70-percent-of-americans-support-medicare-for-all-health-care
Granted the polling comes out more negative if you call it "socialized medicine," but Mr. Krugman admits that he is among the more recent converts. ...after the polls showed it is now so popular.
If you start off with a weak bargaining position, which is the way health care reform was proposed by both the Clinton and Obama administrations, then you will still have to compromise, because no matter what progressive legislation you offer it will still be called "socialism," by the Republicans. So Obama proposed a plan very similar to that was promoted by Romney when he was governor of Massachusetts and it still got chopped up in the political process, even though it was less progressive than what Nixon proposed in the 1970s.
If Warren is elected and passes a weak plan in her first year and waits until the "third year" of her administration to propose what the majority of the people already want, then most likely she will be in a weaker position in her third year (after the mid-term elections) and the health care system will continue to be the complicated expensive mess that it is now.
If Bernie Sanders is elected he will also have to compromise with the Republican House, but at least he will not start off in a weak position.
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@Robert Scull
The precise language of the question was "Would you support or oppose providing Medicare for every American?"
That question could mean single-payer or it could simply mean a Medicare opt-in which keeps the structure of private insurers intact. It can't be construed as a support for Sanders' plan.
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@Bill B
Wrong. "Providing Medicare for every American" is not the same as "giving every American the option of Medicare." To get the results you would like to see, the question should include the word "option" or "choice" rather than the word "provide." But those words are simply not there.
Likewise the wording of the question also includes the word "every American," not "some Americans" or "all Americans who want it." It simply says "every American."
So it was worded in such a way as to exclude the private option.
@Bill B
"Providing Medicare for every American" is not the same as "giving every American the option of Medicare." To get the results you would like to see, the question should include the word "option" or "choice" rather than the word "provide." But those words are simply not there.
Likewise the wording of the question also includes the word "every American," not "some Americans" or "all Americans who want it." It simply says "every American."
So it was worded in such a way as to exclude the private option.
Sheer will power, resolve and ability to stake large political capital is what will produce advances toward universal Health care. It almost does not matter the specifics of which candidate supports what precisely and resistence from vested interests will be enormous, not to mention republicans; but the candidates who are already hedging will not be the one that voters should be counting on for expanded healthcare. They will be the most reluctant to stake political capital. Hence why I support Warren and am skeptical of Biden, Buttigieg and even Booker.
As an aside I wish Elizabeth Warren could articulate more clearly the long term and tangible benefits of a Medicare for all plan, a plan that at last eliminates a huge amount of work related stress for the Middle class. Fears of losing a job, losing benefits, a catastrophic illness exposing to ruinous co-pays and excluded items. She and Bernie should also emphasize that the moderates are at best hypocritical: either they will ensure universal Health care (but not Medicare for all) in which case their plan will actually cost much more and keep all the inefficiencies and result in much higher taxes, or they have no intention to actually fight for universal health care and instead simply come up with some public plan that people with enough money can opt to join. Devil is in the details. Only Warren has had the courage to spell out her plans.
IF the federal government can ACTUALLY provide an acceptable alternative to those currently in the private system there will be little problem in moving to single payer especially if it can be delivered with lower cost to to the individual. Most in the high functioning parts of the current system have extreme doubts that this can be done.
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@BrookfieldG Seeing as how the VA can do it on a large scale, as long as it is not being hollowed out by political appointees and incompetent admins, like we have a large % of Everywhere (what is it, 30% of CEOs can be considered psychopaths?) but the VA System ran rather well for me, in different places it is better than others, but that is politics and money allotted.
Set EVERYONE to Single payer, make it a level doctors can live on, nurses paid separate etc, and overturn this profit motive in medicine which did not come about until after WWII. The AMA was formed to make medicine For Profit, where it had been legally non-profit, all hospitals etc, prior.
It is time to go back to a Non-Profit, single payer system covered by taxes on corporations and those with paper wealth, since that paper represents people working for companies, the workers need their share of the profits in way of real health CARE, not deadbeat insurance that never pays and has all kinds of excuses not to.
Lets get away from the corporate death panels of today and get on to caring equally for all! We can easily afford it if we quit giving away tax breaks to those who need them least.
So I KNOW Socialized Medicine, tax payer covered, works, it just takes getting the greedy lot out of the pig trough that takes so much away from us, including public trust.
Medical CARE, not 'insurance'.
I filed my papers to enroll in Medicare two years ago.
It’s wonderful. Even generous. I’ve been struck with sciatica and neuropathy since that time, and Medicare covered a hefty portion of the doctors’ bills and charges for hospital tests (CT scans, bone marrow biopsy, 26 vials of blood taken at one sitting, ultrasounds, etc etc).
The full prices of these visits and tests have astonished and angered me. $5,000 here, $3,000 there. My husband is tired of hearing me ask him how anyone in the US could manage without health insurance.
Enough already. If nations in Europe, Canada, Scandinavia and elsewhere can establish systems to protect citizens (and visitors!) who are ill, we should be able to. Control prices of prescription drugs. Control the inflated prices charged by hospitals. Make Medicare available to those who need it. Charge the Koch Brothers, Bill Gates, all the Trumps, Big Banks, oil companies, and friends their fair share of taxes.
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@Deborah - yes, and it is important for stories such as yours to be more widely known and understood - the private insurers will perpetuate the Medicare/Medicaid/VA horror stories ad nauseaum simply to protect their business - but reality is that they add zero value to the healthcare process and must be eliminated if profligate behaviors, out-of-control costs, and waste/abuse have to stop. But, as they say, a known devil is better than an unknown devil or angel - so good stories about Medicare are necessary to convince the public that Medicare for all is an angelic option after all
A good therapist knows where an individual needs to change certain patterns of behaviors or thought. What u dont know is the emotional readiness of clientelles abiltiy to accept anxiety provoking changes in perspective. Usually you would incrementalize your approach to less threatening strategies to assist in getting from a to z. Sounds like this would be a good premise for changes to social policy as legislators need to understand and respect the homogeneois nature of the electorate.
2
Americans don't care who pays their medical bills as long as they are paid and they can pick their own doctor and hospital. That surprisingly, is the promise of single payer and no other reform package can do that. By paying hospitals and doctors directly, we cut out nearly 1 trillion dollars in administrative overhead which can be used to fund far bigger needs like in home care, long term care, occupational, mental and public health. If we could prevent illnesses or disabilities in the first place, clean up our environment from toxins, get people counseling when they need it, we could join the rest of the world in improved life expectancy.
7
Warren is a very smart woman. Not only with a plan for most things but savvy and flexible enough to read the country and make changes. She does need as many votes from privately insured people who are happy with it. Make them comfortable too. If she gets to be the democratic candidate, inclusiveness will contrast dramatically with her opponent.
Now she should tweak step 2 in a way in which medicare for all includes private insurance. This is a country of having choices and, I am sure she can revamp the budget and the tax laws to make it happen with both options.
4
I agree with Prof. Krugman. When Huey Long was governor of the state I was born in, Louisiana, he famously took a map of the dirt road 'highway' system for the state, and marked a mile or two in every parish to be paved. He predicted that once people got a taste of the glory of pavement, they would demand more. He was right, but it is harder to find incremental changes with big benefits in health care than it is with roads.
5
@Donna Mohr
When Louisiana expands Medicaid and the ACA and one person is insured and that person gets a colonoscopy or mammogram and cancer is detected at an early stage and it is treated and the person is in remission--that's a big benefit to the person and all the people that love that person.
"The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform."
It was Sanders's 2016 campaign that opened the path toward Medicare for All.
@Ann No, it was that it wouldn't be on the table for Obamacare to be drafted. Nothing like putting a muzzle on Americans right when they have no healthcare access at all and having their hands tied by a recovery that saved only those with money already put a fire in their bellies. Bernie came later, much later.
3
It's probably just me (or maybe not), but I can't understand the position that insists on Medicare for all on day one as proposed by the Sanders camp. Virtually everyone knows that this approach will never make it through Congress. And although I totally agree with the appeal and goal of this plan, demolitioning our home in the middle of winter with no real architectural design, general contractor, building supplies, and financial plan yet in place, where will we live? I don't know if this is an appropriate analogy, but all things considered, I'd rather buld an extension on my existing home so I know I still have a roof over my head.
9
@kg Your analogy is spot on.
I believe that the most effective evolution of a national single payer system will result from the merger of single payer systems that will be initiated in large population states such as New York and California, and subsequently include less populace states, such as Vermont, Connecticut, Oregon.
1
As usual, Professor Krugman loves himself some incrementalism. As in the law, where justice delayed is justice denied, so too in healthcare: Universal healthcare delayed is universal healthcare denied.
It's almost as though the people promoting the "two step" approach to Medicare For All (cough, Warren, cough, Krugman) aren't really interested in Medicare For All at all. Their protests to the contrary, both are in thrall to the Medical Industrial Complex, to the corrupt status quo.
No thanks.
Sanders 2020
5
@Greg Gerner This sounds like an always trumper except sanders replaces trump.
1
Some truisms which may help explain why people resist crusades: many, if not most, people do not like change; the haves do not want to give up much, if anything, to fund the have-nots; politicians' promises are not believed; the system is rigged against the little guys; the little guys love freebies.
1
I agree that Elizabeth Warren’s 2 step approach is the best way to get to single payer. Good column.
7
Yes Prof. Krugman! Thank you for writing:
"there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger."
9
A 2-step plan does sound like the only way.
But in saying this we need to spell out the negative consequences of the first step as well as the positive ones. Unfortunately, fixing our health care system is not likely going to turn into a simple step by step process forward. Our current system is too dysfunctional to be fixed by incremental adjustments.
Krugman assumes that “successful health reform, even if incomplete, creates the preconditions for further reform” and that “initial reforms [could] deliver concrete benefits, and maybe provide a steppingstone to something even bigger.”
But as we have seen with Obamacare, the benefits coming from the first step are likely to come with serious costs and opposition as well. Furthermore there are practical limits to what benefits can be squeezed into our current health care system, and there are many costs that are unavoidable. Obamacare already picked the low-lying fruit. It did not, for example deal with the scope and power of private insurance.
The first step, Krugman’s “incomplete reform”, will likely serve as a precondition not for further reform , but for major structural change, and we should be able to say this and prepare for it.
The initial reforms may benefit some, but they will undoubtedly also further the disintegration of the mess we currently call a health care system.
We cannot wait for the collapse of what we have and only then build a better system. We need to begin building the new before such a crisis.
3
@Just Thinking’ No, Obamacare has brought what could not even be discussed, single-payer, to the forefront of the discussion today. It's self evident that “initial reforms deliver concrete benefits, and maybe provide a steppingstone to something even bigger.”
Enough with the but . . . (put anything here) that is nothing but food dragging defeatism that is killing thousands of Americans some more quickly than others.
1
Compare two promises from two candidates:
Promise 1: If elected, on day one, I’ll start building a wall and Mexico will pay for it.
Promise 2: If elected, on day one, I’ll pass legislation providing Medicare for All and the billionaires will pay for it.
The common denominator between the two sets of voters is anger. Anger is what blinds them to the impossible nature of the proposed solution.
5
@J
I will never understand why anybody would compare Sanders to Trump, as if they share a common denominator. Sanders is the complete antithesis to Trump--and anger at a system that buttresses billionaires who also loathe economic change and activity push against it in one of the most unequal countries in the world is justified.
@J No, the momentum behind the wall and warren's plan is in no way similar. Trumps is cynical manipulation of a minority of racist, ignorant white men and the people whom they can press into doing what they want.
Warren's plan is from a consensus of a majority of Americans who understand our system is helping no one but a few wealthy capital holders and people are seeing their lives shortened by it and one in 5 of us know someone who was killed by it.
No, these are not the same motivators at all.
1
"there is a good case for EVENTUALLY going single payer" Dr. Krugman
"The long run is a misleading guide to current affairs. In the long run we are all dead. Economists set themselves too easy, too useless a task if in tempestuous seasons they can only tell us that when the storm is past the ocean is flat again." JM Keynes
A relatively short transitional period, incrementally building both single payer care and support for it over a relatively short time frame as Warren is proposing is a very smart alternative to full on immediate MC4A. Coming from Warren is anyone surprised that it's smart and well thought out? The American people need health care now not only in some far off future that will never come unless we fight hard for it now. But a incremental approach on a pretty fast time track is a very decent compromise with political reality. Obamacare aka the ACA has shown the merits of incrementalism but also its dangers. It's certainly true that support for ACA is far higher now than when Obama and Pelosi passed it into law. It's also true that many have been disheartened by ACA - it's expensive, it's deductibles are so high that many low income / low wealth Americans still can't afford medical care, it leaves medical care mostly about profit. An approach that is too incremental will never generate much support - but too fast will scare off too many to ever pass.
4
Single payer shares with Biden there misguided belief that there exists an element of reasonableness within the Republican Party. It will take the equivalent of the falling of the Berlin Wall to break the GOP out of its idealogical lockstep. ACA+is an approach that can produce results.
If memory serves, soon after being elected with an historical mandate, Obama proposes a "medium-size reform." He didn't sell it to the American people (the Republicans spent the summer convincing their constituencies) and quickly lost both houses of Congress (59 Dems in the Senate? But didn't W. get us into an endless war with only 51 Republicans?).
He accomplished little and we console ourselves blaming Republican obstruction.
Go big or go home. I think a Dem president needs to aim high, then negotiate with Congress (both houses, both parties, both conservative and progressive). Look what Obama's negotiating against himself (not even proposing anything he thought the Republican majorities would find unacceptable) got us: six years of stasis, and a dissatisfied Trumpian electorate.
12
I think it's come to the time when we need to simultaneously push for lobbying reform as hard as pushing through a single payer system (with private supplemental insurance available). If we can't stop the bribery of our officials by the big moneyed interests, we can't get anywhere near the policy we need. Keeping the rich entrenched is their Job #1, and any legislator not willing to take the dirty money gets swamped by the rest. That's the system we have to eradicate to get anything worthwhile done, whether it's affordable healthcare, meaningful environmental regulations, justice system reform, consumer protection, literally ANYTHING. It all starts with stopping the dark money flow that corrupts our elected officials. Who, by the way, seem to really like rubbing elbows with the fat cats and rolling in all that dough.
12
The ACA was signed by Barack Obama in March, 2010. I know because I was an RN Case Manager during the recession trying to help hundreds of patients who had lost their healthcare insurance when they had lost their jobs. It was quite emotional to see this signing and to know people who became patients might, with the ACA, have a better chance at life.
Of course the law did not go into affect right away, but it finally did under Obama’s tenure. People could finally shake loose, work for themselves and buy a reasonable insurance plan.
However, the Republicans despised Obama’s success, did everything they could do demolish the ACA. They did nothing to improve the terms of the policies. Certain corporations, such as Hobby Lobby sued and alterations were made through the courts, such as women’s access to contraception. for one. All in all, Republicans allowed the plans to increase in price and did nothing to make the ACA more affordable and actually took glee in making it less affordable.
In the meanwhile Americans struggled again, trying to find alternate, affordable plans, but the Republicans continued their ACA insurance decimation. Remember Trump getting together with Paul Ryan and House buddies when they came close to ousting the ACA - and the Senate would have, save for John McCain’s vote.
All these years, all these people could have worked to make the ACA better, negotiated to make it more affordable. They direly failed us.
And here we are, still trying.
20
@MIMA
Perhaps Mr. Krugman's looking back on the origins of the ACA, passed by the Democrats under President Obama, as well as its near demise at the hands of the Republicans and President Trump, will serve to remind voters that Republicans did not, and have not for decades, had our interests at heart. In fact, they have been working against the interests of working, middle class Americans. We would do well to remember this next November.
7
This is a sound argument, assuring that the dark side will stop at nothing to defeat even incremental progress. It won't be fun to endure.
3
"Some physicians refuse to participate in or accept Medicare. How will these entities be persuaded to accept only what the government pays?" 1) Find physician who accepts Medicare, 2) Pay for supplemental insurance which covers the cost.
Seems to me that the ultimate result of all this consideration over healthcare insurance currently suggests a mix of Medicaid + supplemental + Medicare ... Basic - desirable - Catastrophic with three joy sticks with which to titrate an equilibrium among them.
2
@Martin Byster Yes and what a massive waste of human capital and productivity. All that titration provides zero value. The only service of value in question is the actual care.
Let's add up the value of unpaid labor that every person puts in just bushwhacking insurance.
4
Warren does not have a two step plan. She realized she was hammered into a corner on Medicare. As Buttigieg said during the last debate ‘she has a plan for everything except M4A’. So she scrambled to put together a plan and how to pay for it. Why, because she knew it would be explosive when people see the cost. She has now been hammered into another corner, which is it is outrageously expensive and as Obama said last Friday, the 170 million people with private insurance for the most part like it. Warren knows she could loose on M4A so she has back tracked. Krugman is doing the same: flip-flopping in this issue now that the truth is revealed.
1
@Brian We need to stop reifying dysfunction and confusion.
Reframe: how can working people possibly continue to keep paying for unaffordable: deductibles, co-pays, coinsurance, premiums, medications?
The cost is a red herring; it saves money.
The real question is why we should allow middlemen to extract 5% profit plus admin cost? Why would we want the thicket of admin and haggling saddled upon doctors office. We pay for that! Everywhere else they don't
We are getting hosed. How can we afford THAT?
18
@Brian The problem with this criticism is it claims Warren promised a magically instant plan when she merely came up with a workable plan that takes into account the fears of moderates. Warren's plan shows not only that she can come up with a plan, one your boy Buttigieg has not and can't from experience as mayor of a tiny city in fly over country, but is brave enough to put it out there for everyone to access. Some people aren't happy with anything and will lose the rest of us to Trump over it if they're not careful.
9
@Brian "The 170 million people with private insurance for the most part like it".
I've got private insurance and it's actually better insurance than most. I hate it. I don't think I am in the minority either. The insurance company conveniently makes mistakes all the time (to their advantage of course). It costs too much. It's too complicated.
12
She flubbed a huge chance to go full Berni in explaining how single payer will save working people money.
Democrats need to speak to the intense economic stressors of most people in a real way.
Taxes are part of this.
Single payer will let people keep more of their paycheck; dems need to show how.
A steady barrage of memes and tight message.
Could anyone be trading out the interests of policy for the interests of "fundraising"--legalized bribery?
That's what sunk Obama's Public Option. Rahm Emmanuel was reported to squash it because the Dems needed pharma money for the midterm election.
All that must stop. Oh wait.
1
@GenXBK293 Doesn't this miss the point of the article? The gist is that if you insist on going for all or nothing, then you're taking a losing bet as very likely "all or nothing would, in practice, mean nothing."
I'd suggest that democrats need to be less puritanical (and woke) and vote for policies and people that will win, which will mean progress. Going extreme progressive (Bernie or Bust round 2) will give Trump 4 more years.
6
@archean1
Yes, getting things done is important, the question is how.
Why did a whole bunch of Obama voters switch to Trump? Compromising on principle has caused most of the country to lose faith that voting even matters.
"All or nothing" is a straw man argument. We're talking about whether we make a concerted effort to gain shared understanding around a policy goal, then rally.
In the CNN debate, Bernie explained how single payer lets you keep more of your paycheck. But all Warren did was say costs will go down.
Meanwhile most Americans including educated people don't understand how single payer works.
It's not about puritanical, it's about rebuilding trust.
Then, how can Dems get back the former Obama voters who switched to Trump???
@archean1
"All or nothing" is a straw man argument. We're talking about whether we make a concerted effort to gain shared understanding around a policy goal, then rally.
In the CNN debate, Bernie explained how single payer brings costs down. But all Warren did was say costs will go down.
Meanwhile most americans including educated people don't understand how single payer works.
It's not about puritanical, it's about rebuilding trust. For the half of the country that sees no point in voting.
Then, how can Dems get back the former Obama voters who switched to Trump???
There is one insurance provider in my state under the ACA. No competition, just one provider. Having no chronic medical conditions and taking no prescription medications I still pay $8400/year in premiums with a $7500 deductible. For ONE person.
If I do choose to use my insurance I can expect to spend 2-3 days making telephone calls to every single provider to see if they are in network and how much they will charge me.
My insurance company is a legal scam. I cannot wait to get on Medicare.
45
@June
Hope that your spouse is the same age or older than you. My wife still has 5 years to go to Medicare, so I pay for the Medicare supplement as well as private insurance for her and our kids under 26--not cheap. Having more than one insurer in the state doesn't seem to help--calling around (another task that takes days) shows they are all roughly the same price.
4
The cynic in me says the powers that be would “support” an incremental policy under the guise of being reasonable because they would prefer to fight it in a series of smaller battles versus the broader M4A war.
I'm not sure how any of these plans address the high often astronomical charges by pharmaceutical companies, hospitals and doctors in the US, A colonoscopy can cost $20,000 or more depending on the number of polyps that must be removed and biopsied. Even if Medicare allows the entire charge, it only pays 80%, requiring the pateint to pay the other $4,000 or obtain secondary coverage. Some physicians refuse to participate in or accept Medicare. How will these entities be persuaded to accept only what the government pays?
6
@Alan J. Shaw If only there were other examples in the world of different ways to do things. I'm trying to think of countries where physicians, hospitals and pharmaceutical companies all shut down when the govt tried to regulate the market. I can't think of any extreme examples so either:
- The doctors all quit and everyone died.
- A system with some sort of regulation or govt control can cut the cost of a $20K colonoscopy without the world ending.
Maybe I'm a bit sarcastic, but everyone agrees the current healthcare system isn't perfect. So many proclaimed that Obamacare would be catastrophic and the end of the world (death panels?). It's not perfect (worse because of those who try to sink it), but nonetheless it made many steps in the right direction. What are the next steps? Is it necessary to try and jump the entire staircase in one leap? Is that possible?
3
@Alan J. Shaw
I am over 85 and I declined the colonoscopy my doctor suggested years ago, when his clinic acquired the necessary equipment. My 50-year old son just had a colonoscopy, not because it was needed (it was not), but because he turned 50 (he has full employer-provided insurance).
Doctors are "milking" the system and their patients' insurance. Question: would a 50-year old man without any insurance be "strongly advised" to have a colonoscopy?
1
@Alan J. Shaw
We have long known that we pay too much for everything related to healthcare in the USA--and oversell almost all of it. Hospitals are culpable in those out-sized charges you mention--often those charges are dramatically cut by an array of insurance plans: https://www.nytimes.com/2019/09/01/opinion/hospital-spending.html .
With respect to exorbitant costs for US citizens, the price we pay for administrative overhead is among the most onerous in the world. There are sensible ways to cut those--without going to Medicare for all: https://www.help.senate.gov/imo/media/doc/Cutler.pdf (Senate testimony of David Cutler, July 2018).
There are any number of other ways to address our situation, but none will be simple, all will require compromise, and all will require Congress to act--something that is also not so simple.
With a parliamentary election in December the politicians are trying to win voter's approval. Both right and left wing parties are arguing about who is going to improve the National Health Service the most after the Conservative austerity made it underfunded.
Still it is good enough to keep me healthy at age 91.
8
If ya have a plan that is not "doable," you don't have a plan. Yes, to any step that will lead to another step towards better health call (not health insurance) for more people and someday for all people.
5
@ggallo -Sorry. "Care" not "call."
You don’t get to MedicareForAll by starting from a compromised position . Elizabeth Warren’s retreat is being lauded by all the usual suspects as rational and sound when it’s more accurately pre-capitulation to biased interests who have no intention of disrupting the healthcare gravy train .
It’s almost amusing to me how those being best served by the status quo embrace the myth of gradualism and incrementalism. They don’t see or feel a crisis so there’s no urgency to act boldly and aggressively -besides they may be slightly inconvenienced ( another myth ) and we can’t have that .
The fact is delaying the push for MedicareForAll by making it a convoluted and needlessly segmented process is a guarantee that it will fail and only serves those determined to see that result .
Political capital is fleeting and has to be used when it’s most potent and available . The GOP knows this . It’s time the Democrats learn this lesson as well .
Elizabeth Warren panicked because her campaign was stalling and flatlining and she started feeling the pressure from corporate media and liberal/centrist punditry to “come to her senses” on healthcare or else .
The or else is the end of the favorable treatment she was getting from media based on their assumption she would fall in line and modify her healthcare stance to appease the powerful forces hostile to reform .
Elizabeth Warren chose the path of least resistance and effectively doomed her campaign .
3
@Paul G Knox To offer a government option to all is a wise plan, so long as it voluntary. If there are financial and other benefits - as there should be in a not for profit system - this should become evident in three years and the populace may well prefer to shift across. Coercion would be counterproductive.
13
@Emoticom
Agree with you although I think once there is private option that works fairly well, whether people want to shift or not, companies will find ways to "encourage" it. Consider what happened to traditional pensions; that's the future of company health care. They really don't want to be in that business.
2
My husband and I own a winery. I really don't want to be in the health insurance business. I also have to have my day job, in addition to our winery, so that we can have health insurance. If there was a Medicare for all option, my employees could go with that, or private care. But I would not have to make the decision for them. And, I could choose Medicare (instead of sorting through the really tired options my employer as, because insurance company costs are out of control) and leave my day job when I want, instead of being tied to it. I am not sure what the dig on 401k's is about. I would much rather have my retirement savings in an account that I control than in a pension that the company can yank when they go bankrupt. that seems like quite a gamble to hope that the company will do right by you. You have to have not been paying attention for the past 20 years if you still believe in pensions. So, if your argument is that businesses already forced us to manage our own retirement, you are right. And, I would rather manage my own healthcare, thank you, without my employer's limitations.
4
Facts will surely show this is the right path. And common sense will progressively be less uncommon.
6
I agree but believe the stronger argument for a two-step process is that many who want Medicare For All, many who need it, need improved and more affordable healthcare now. Tomorrow, fighting for years for Medicare For All, will simply be humanly too late for many very real people.
It's so easy to forget that actual lives hang in the balance that even those advocating universal healthcare can forget it in making that very point. Indeed, that lives hang in the balance is a good argument for a truly universal system, but it is equally an argument for delivering tangible, life-saving benefits to as many people as possible as quickly as possible.
With a Democratic victory, as Prof. Krugman writes, the relatively low hanging fruit of regulatory and administrative actions, ACA expansion to more states, and a public option, finally, cannot be ignored. In any event, years of aggressive and proven effective tax reform, ratcheting up taxes on the wealthy and corporations, is a precondition for any plan such as Warren's, financed as she proposes rather than Sanders' more conventional method. The two-step approach she's now formally advocating amounts to a recognition of the imperative to do everything possible in the meantime. It's too much to suppose that both Medicare For All and a fundamental restructuring of our tax code, also needed for Warren's many other plans, could be passed in the same year.
And Democrats will only survive 2022 and 2024 if they tangibly deliver in 2021.
9
What has to change is red state hostility to sharing the burdens of health care, and the red state habit of distrusting and disliking government more than big business. Making health care more widely available can help change both these things by showing red staters that the health system and the economy can both survive and even prosper under a little more government.
As far as dyed-in-the-wool racists and devout evangelicals are concerned, change will mostly happen by some sort of conversion experience rather than careful calculation. We need to work on triggering these experiences as well as presenting logical and evidence-based reasonings.
7
One very good reason for having Medicare For All is that the United States is not producing enough babies. Women are having babies at a pace that is well below the replacement level. We need 2.1 babies per woman but women are having only 1.7. One reason is that potential parents are worried if they can afford the expenses that are incurred when they have children and medical expenses are a large part of the expenses until the children fly the coop. Take a look at Denmark. If any country should be stocked with babies, it is Denmark. The country is one of the wealthiest in Europe. New parents enjoy 12 months’ paid family leave and highly subsidized day care. Women under 40 can get state-funded in vitro fertilization. But Denmark’s fertility rate, at 1.7 births per woman, is roughly on par with that of the United States. Will similar incentives make American women become mothers?
I get the issues around the decision making. We have one child. Yet don’t we promote contraception and family planning in less developed countries and communities, while you’re talking about increasing birth rate in affluent countries. As far as I know, the total world population is still increasing and humans migrate. Perhaps a more humane immigration system is what we really need.
@Indian Diner
Just for the record: women are not nesting boxes.
Please, don’t be ridiculous, the planet is collapsing under the burden of humanity. More babies is the last thing this planet needs. Have you not been paying attention, the climate is an existential threat to almost every species on the planet, yet you want to increase the population. Do some serious reading on this topic and open your mind, WE ARE VASTLY OVERPOPULATED!
What people want in healthcare is certainty.
As a five-time cancer survivor, which is a stress-based disorder, I can tell you people live in constant fear of the GOP undermining ACA. Year by year there is the constant worry and concern about how will I get to next year? Will I be able to get coverage and what will it cost? Employers fire employees with cancer. They also cheat on disability policies claiming you did not work enough hours, while in cancer treatment, to continue to qualify as a full time employee so they can cut your disability pay in half. At one point in my sixties, I had to become a student to be able to purchase enough insurance to get me through to Medicare at 65. In a hot mike moment, Senator Chuck Grassley was heard to say, “Don’t let them have Medicare because they will never want to let it go.” Yes, I want to know I can live. I want the certainty of healthcare. I want that much certainty to be able to work.
I want to be employed at work that I love rather than take a job because I need their insurance. I want something permanent rather than be an indentured servant for health care.
46
A government provided and managed health care coverage system would eliminate the expensive profit motive, more truthfully be an insurance pool as theory goes, result in incredible efficiences and advances through total information sharing, be a remarkable source of statistical information to accelerate better health modalities, but most important; it would change our way of life from a hostility of armed desires individually and militarily into a land of caring and incredible longevity and health.
The Democrats have been dutifully plodding forward to save Americans. The Republicans actually convinced their psychologically seduced base to vote against their own well being.
While opposed to each other in campaigning, all Democrat candidates should set aside their pride if elected and combine the popular aspects of all candidates' health care ideas to logically get to the next step that will mean a program advancement that will be highly attractive to all in the future.
4
We lose sight of that fact that Obama also would have preferred a single payer system. However, the practical side of him understood that it was politically impossible to achieve. He opted for what he could get, and we are all the better for it.
We are currently a nation at "political" war. We need some moderate ideas to help bring us back to a civil political discourse.
We are as likely to get medicare for all as we are to get ALL guns off the street.
We are experiencing a leftward "evolution" in this country - euphemistically correlated with the urban-rural divide, with the suburbs shifting toward the urban. This evolution will continue unless we try to turn it into a "revolution."
4
@MS "He opted for what he could get, and we are all the better for it."
Not true. Medicare recipients are paying the price for the money Obama took from Medicare to finance the Affordable Care Act. Medicare, which once provided affordable coverage, was undermined by both Obama and George W. Bush (Medicare Advantage), so that retirees on fixed incomes either have to forego specialty care or purchase a prohibitively expensive Medicare Supplement or subscribe to an inflexible Medicare Advantage plan.
4
Usually agree with Prof. K, but his analysis of GOP win in Mississippi by not having expanded Medicaid makes no sense. Implies that GOP strategy for winning is to never expand Medicaid coverage in that state - sorry, don’t agree.
Now back to agreeing with Prof. K: Vote Warren 2020!!!
3
Our nonparticipating state appears to be no more likely to expand medicaid than it was five years ago, even with the 2 million spent by health care providers in the state driving a campaign to do this. IMO, Paul Krugman is either clueless or being dishonest about middle America.
Last week he claimed that our farmers are social parasites - when, if anything, WE are the hosts - and then extended this to include ALL rural Americans, calling us "wards of the state"! This is out of line - and his faithful readers parrot it in their comments. The USDA-based figure cited by Dr. Krugman that 40% of farm income is associated with government support is evidence that agribusinesses may be, to some extent, wards of the state. But not most farmers who have to compete AGAINST these subsidized corporations that shape our Farm Bills. Farm income is not "normally" distributed across the farms of America and Dr. Krugman must know this. Most American farms have under 100 acres and often require outside employment to pay the bills (like ours) - and these farms do not receive direct farm subsidies (it's not cost effective to apply for them). Concluding from this that American farmers (and even all rural people) are hypocrites and leaches, when we actually protect the nation's food supply is irresponsible. If water, petrochemicals and/or energy becomes interrupted, corporate farming will be rendered near useless. Food security is national security, in addition to our cultural heritage.
5
@carl bumba
Thank you NYT for posting this comment, in timely fashion no less. (Maybe it was too tedious for their algorithms to read through, as well.)
Paul ...
I wonder if you have read Public Citizens "Medicare for All." They have been encouraging this for many years.
I have not compared it to anyone else's plan.
Why not a government sponsored healthcare plan that would compete with the private insurance market? This would not be Medicare for the elderly or Medicaid for the indigent, both of which could stay in place, but a reasonably priced alternative to the current insurance market.
2
@Michael
If you look at most countries where private insurance is used to attain universal access to healthcare, it is made reasonably priced through the use of government regulation of prices.
In switzerland, for example, the government sets physician, hospital, and drug reimbursement rate. As far as I know all payment comes from private insurance, and it is compulsory to purchase insurance (individual mandate). The only reason it is cheaper than that in USA is because government sets prices.
The reason insurance is expensive in USA is not so much because of a lack of competition in the private sector, but because everything that the insurance covers costs so much more than everywhere else.
Physicians are paid 3-10x as much in USA vs many european countries.
The government does not use its power to either negotiate or regulate drug prices. Things like insulin cost 1/10 as much in Canada, and are even cheaper in much of europe.
There is often a lack of competition among hospitals in local healthcare markets (1-2 providers own all the hospitals in an area), and no price regulation, so insurance companies pretty much have to pay whatever they ask.
If the government creates a competing public option, and does not regulate prices, it will be no cheaper than current private options. If the plan is not reasonably priced, there is not really a point to it.
2
The strongest arguments against the Warren/Sanders healthcare plans are it will never pass the Senate and it gives Republicans a lot of ammunition for the elections. If they would propose a healthcare plan like any of the European countries with a realistic phase-in period, it might have a chance. The W/S plan goes far beyond what European countries (or any other country in the world) have. It pays for everything from dollar one. Other countries with universal care pay about 80% of all healthcare costs publicly, with the remainder paid by the patient and/or a supplemental insurance policy. Some commenters will write that that isn't true, but one has to only use the Google machine to see that it is. Canada's public system pays more like 70% or all healthcare costs, for instance. The Canadian public system does not pay for all dental care, vision care, limb prostheses, wheelchairs, prescription medication, podiatry and chiropractics and ambulances. Canada’s provincial and federal health insurance covers standard ward accommodation (four beds to a room) through Canada’s Medicare program. A private room or semi-private room will cost you or your insurer $200 to $300 a day. All personal and nursing care provided by long-term care homes in Ontario for instance are funded by the government. You must pay for accommodation charges such as room and board. Accommodation charges vary from $1,900 for basic, to $2,700 for private rooms. The W/S plan covers all of everything above.
5
Sanders Medicare for All bill has a 4 year phase in. Join us!
@Ray Katz: I don't think 4 years is long enough. But more importantly, Sander's plan has zero chance of becoming law anytime soon, and the Republicans and their propaganda machine would make a lot of hay of it in the campaign. Then there is the fact that it goes way beyond what public systems in the rest of the world offer.
1
Thanks Krugman for endorsing warrens two step. I’d prefer MFA tomorrow but I can see it would be hard to make it happen right away (senate, private sector interests etc). The insurance companies would hate it. One thing that’s puzzling is this idea that people like their employer based insurance. Other than those with union plans which are frankly too rich for anyone’s good, everyone I know hates their employer basedinsurance. And people love their Medicare. If it’s ok for old people why not the rest of us?
3
I'm always perplexed in the US health care debate about why universal health insurance is equated with single payer.
All other OECD countries have universal health insurance for both working and non-working residents, but only two have single payer: Canada and the UK.
There are plenty of other systems to learn from that all have lower costs and better outcomes than the current American mess, such as France, Germany, Japan, the Netherlands, Switzerland, none of which have single payer.
8
@gs
A correction-
New Zealand has single payer and is a member of the OECD but point taken. It is indeed mystifying that many American politicians and citizens alike seem not to recognise that single payer is but one way to achieve universal coverage. There are lots of ways to get there as you've pointed out.
5
@gs I have lived with the French system for almost 50 years. When I arrived the public system paid for 90-95% of medical expenses (except for glasses, dental, etc.) What now seems like a small "moderating %" had to be paid by the patient, so people wouldn't just go to the doctor or hospital for no reason, as if anyone did that. The public system now only pays for about 80% over all, and is declining. This has been done in order to get some or all (I suspect that is what they want) medical expenses off the public budget and record. So then you need private insurance to cover some of the rest. So we pay to administer the public system, then we pay to administer the private insurers as well. Two people doing the job that could be done by one. I would approve Warren's progressive plan toward a single payer, as the American system is in such a deep hole that we can't just jump out it in a single step. It will take years of struggle.
The “good case for eventually going single-payer” has been going strong for over half a century: Kaiser Permanente.
They are their own insurer, at a national level (across many states), having instituted their own non-profit insurance corporation, covering many tens of non-profit hospitals (that KP owns); and equal tens of medical groups that are for-profit—all KP components, a 3-legged national system.
This has allowed cost-effective quality improvement through long-held collaborative relationships between the insurance leg and hospitals, which are resourced at a national scale, affording economy-of-scale cost-effectiveness.
KP was “in the room” when the ACA was written. They are the best available longstanding model for how integration of non-profit insurer (which is what the government is, as Medicare/Medicaid agent) and non-profit hospitals can work excellently with for-profit medical groups.
In an important sense, the ACA is already a scaling up of many KP components. But a closer examination of their 3-leg national sysem models a lot of what Medicare-for-all may eventually look like.
5
Krugman's centrist prejudice against Medicare for all, or any other form of socialized medicine is long standing as he admits, but with the fig leaf "as a purity test". He's just nakedly against it. Naturally, he interprets the Louisiana and Kentucky election results as confirmation of his ideology. Never would Krugman darken the Op-Ed page with an explanation as to how the U.S. could use the funding formulae that exist elsewhere to implement federally funded universal healthcare sooner rather than later. Nor would he attempt to disabuse those Americans who are "unnerved" (Krugman's description from an earlier article to denigrate Warren's and Sanders' healthcare plans) of their nervous condition. For Krugman, the later, the better, and never would be best. His hero Hillary Clinton and her husband conspired privately with representatives of the medical-industrial complex to create "managed care", thereby making a bad system even worse. Obama's incrementalist approach was a lateral move that benefitted some while penalizing others. Krugman would be unique among his Op-Ed colleagues if he supported federally funded health coverage in any form. The New York Times is a corporation that is not about to interfere with the ability of corporate medicine to make a buck.
7
absolutely; it's just easier to say too bad than to offer anything new, easier to be bad than good, we are such a lazy country
I am 57 years of age, relatively healthy and pay about 800.00 per month for a “silver” policy under the ACA. Every year I need to shop for the “best” policy online tailored for me, as if I have a crystal ball and know what the future holds. When I have awoken from the few minor surgeries I’ve had, I am always shocked by the Co-pays and invoices I receive, over a few weeks, post surgery, from various medical companies at the party while I slept.
I don’t believe that the government can do worse then the every person for themself system we have now.
We can do better - Medicare for all.
19
I don't know why Mr. Krugman is only talking about Warren. It seems to me that all of the other candidates have plans -- and not only Bernie. Biden wants to build on ACA, Mayor Pete is positing an Medicare for All Who Want It etc etc. Let's explore all the plans. IMHO, I think building on ACA is the best plan and is, when you get right down to it, what Warren is retreating to. And FWIW, I live in France where the so-called universal health care hardly covers everything. Most people supplement coverage with Mutuelles for which they pay out of pocket.
3
@jacqueline Friedrich
Because NYT has endorsed her, unofficially. Once they officially endorse her their pretense of being impartial arbiters of the truth will drop away, along with some of their power to manipulate readers.
1
Krugman’s article has three major weaknesses. First, he starts by citing polling evidence about the three governors’ elections and the candidates popular support. He then claims that voters in those states chose their governor based on the state’s Medicare expansion, but he cites zero evidence to prove that voters in those states were aware of the Medicare expansion or that it played any significant role in their choice for governor.
Second, Krugman ignores the fact that voters say they reject Medicare For All until it is actually explained to them. Voters who understand Medicare For All’s likely results tend to overwhelmingly favor it over private insurance. It is safe to assume that a Democratic Party presidential nominee who makes Medicare For All their central sales pitch to voters will actually work to explain Medicare For All on a daily basis during the general election.
Third, Krugman may be correct that incremental change is the safest way for the Democratic Party to proceed. But it has already been ten full years since the Obamacare debates, and Krugman suggests a similar period (ten years) until Medicare For All could be safety implemented. How many Americans will have suffered and/or died over the next ten years due to our consistently sub-standard health insurance system? That number is in the millions, all in the name of Democrats need to feel safe! I know what policies I’m voting for in the primaries!
12
@Rob
Great analysis. Our state is not moving toward medicare expansion. There is a new ballot initiative heavily funded by healthcare providers seeking huge profits, but not by the people. It won't pass. I suspect KY's recent election was a referendum on the unique Republican governor, not medicare expansion. Dr. Krugman, like many NYT writers, knowingly misrepresents the truth, imo.
1
"Sanders supporters are, predictably, crying betrayal." Where? When? Dr. Krugman, you need to back up this demeaning claim. And your depiction of the "the full Bernie" as "...eliminating private insurance and going full single-payer" is utter nonsense. Bernie's Medicare for All plan also intends to be implemented progressively OVER TIME, with the starting age going from 65 to 55, and then to 45, and then to 35, etc.. Furthermore, private insurance will NOT be eliminated, even after it fully covers all age groups in the population. As with Medicare, supplemental insurance for high end and/or elective procedures would still be available for those wishing to pay for it. One has to wonder whether Dr. Krugman even read Bernie's health care plan at all. Even if he has sworn opposition to Bernie Sanders, as it so seems, he should still read Bernie's plan since Elizabeth Warren's is based on it. It's clear to me that Paul Krugman favors half-measures here and everywhere else that might otherwise result in significant changes to the power structure of the establishment.
14
Though not sure if any of the candidates have mentioned this but the categories of plans should be done away with. Even under the ACA and employer covered plans, not all plans are equal. Silver,bronze,platinum,tiers. Everyone should have the same all-encompassing plans, not just "access" to them.
6
There is not a single country on Earth that incrementally developed a universal healthcare system. Every single one of them did it in a single leap. The reason for this is because piecemeal legislation can never get you there. A properly functioning universal system is simply too complicated, and has too many inter-reliant components, to be put together piece by piece.
What Warren is saying, flat out, is that she intends to win the White House and then reserve the fight for single payer until she can use it as a campaign slogan again (at which point, seemingly, she will move the goalposts yet again).
If you want universal healthcare Warren will NEVER get you there. I really wish she was stronger on this, but it now looks like she has chosen to never actually *fight* for it.
Let’s face it: we will never ‘accidentally’ find ourselves with universal healthcare. It will only come after a tough and open struggle.
10
Lower the age of Medicare eligibility to 60. Wait 4 years, repeat and lower the age of eligibility to 55.
Why wait? Take care of the issues that arise as a new cohort joins Medicare.
7
@casesmith
Great approach. Despite what Dr. Krugman states, Bernie's plan goes from 65 to 55, then 55 to 45, 45 to 35, and so on. Never base opinions about Bernie, Tulsi or Yang from anything in this paper; it's the voice (and arm) of the establishment.
8
Turning down the Medicaid expansion money, as former WI governor Scott Walker did, made so little sense you probably had to be a Tea Party person to understand the logic.
The Dems should explain that health coverage has been in their party platform since FDR or Truman and that there are many reasons to make sure everybody is covered--economic and morally.
There are a lot of ways to get there, they should say, but we won't solve this until people stop thinking that they deserve their coverage (Medicare, employer, etc.) but others don't.
It's a big but hidden element of our growing economic polarity.
8
@Grennan
This is a very interesting point. Should health care be a human right or should it not? At which point does health care become a luxury?
1
@Luisa
I'm just amplifying the observation about the different groups made by Paul Starr, the historian whose brilliant "The Social Transformation of American Medicine" became invaluable during the 1990s iteration of our health care/coverage debate.
He brought up the "we deserve. they don't" idea on a PBS discussion fairly recently with journalist Ezra Hayes, who summed up the precondition debate with the question "Do we want to be a society that charges sick people more for their coverage?"
If our country thought health care was a human right, we wouldn't have been discussing it for 117 years; Theodore Roosevelt first proposed it during his 1912 presidential campaign.
So yes, in a lot of ways it's become a luxury here.
In June, I went to urgent care near my home. My insurance plan said not to worry; it would only be a $10 copay. When I arrived, I was told everything should be ok. The next week a denial letter came from my insurance. Now I just paid for the full amount. So what happened?
It turns out that my highly restrictive ACA HMO does not consider that particular urgent care to be in-network. In fact, almost no nearby urgent care facilities (and there are many) are in-network for me this year.
Luckily, I made the correct decision not to go to the ER; there I would have incurred much steeper fees with my deductible and co-insurance.
Meanwhile, I can't see a specialist because I do not yet have a PCP referral. It's difficult to see a PCP because the first visit is a half-hour, hard to schedule because it’s considered a very long appointment.
Last year I had to fight over payment for my "mandated" flu shot due to a possible billing-code error between the clinic and pharmacy.
I realize these problems pale in comparison to those of others with their health insurance. Still, it makes me think what it would be like to live in a country that provides more humane medical services.
I also wonder if America is capable of ever extricating itself from this healthcare mess.
20
@Blue Moon I live in Australia. Here, I pay for private insurance (4K aud per annum) to cover my entire family but we only use it for elective surgery and I have to have it because I’m in the top 10% of income earners (not wealth holders though!). However if we were sick enough for it to be an emergency, we would just go to emergency at the local hospital as a public patient, they would triage and we’d be treated on the same day. No out of pocket expenses. Getting a referral requires a GP visit which is usually very easy to book and max out of pocket is $70 (but that’s just because young income earners here effectively cross subsidize older pensioners who are bulk billed - no Co pay). System has some problems but American stock market analysts have told me we hands down have the best medical care system in the world. Rural dwellers struggle a bit with access but if they’re very sick they are flown to where they neeed to be and not charged
6
@Min
It's tough being an American right now, you know? Especially reading your comment. And with many other things that have been in the news lately.
Also, I forgot to mention that because I made more than I thought I would this year, when I file my taxes I will have to repay many thousands of dollars worth of ACA premiums that were subsidized by the government in advance.
Perhaps on a more positive note, I would like to put out a plug for the flu vaccine this year. We have heard that Australia had a tough flu season, and that is a warning for those of us living in the Northern Hemisphere. I hope we will develop sufficient "herd immunity" as people opt to get their flu shots. A huge benefit of the ACA (Obamacare) is that preventive care is covered at no cost. We all need to take advantage of that. And the sooner the better, because the shot takes two weeks to fully kick in. This winter, be careful touching your face with your hands. Wash up and sanitize frequently.
Be careful out there.
4
In other capitalist democracies, if they don't use single payer, they have insurance mandates---but with the crucial factor of govt regulation of insurance premiums.
The citizens of these countries can afford insurance because the govt they elect regulates costs. Profit is not 1st priority. Here that would be portrayed as unAmerican.
So, compared to U.S., what are their insurance company profits like in these countries? What are their insurance CEO salaries like? Does their medical care industry lobby and donate big sums to politicians to pass laws for high profits?
This information would be crucial in our discussion of our health care system for American voters. Does the economist Krugman have an interest in examining these comparisons---and their political ripple effects? He would be qualifified to do so.
7
Two points:
1. I’ve hoped that Warren would see the political risk in pushing for all or nothing, and it seems that she has. That’s good news. One might ask why not hope the same sanity of Bernie, and the answer is that Bernie isn’t capable of such a rational strategy. He’s so intransigent and obstinate that there’s really no point in wasting time discussing it with him. It’s sad to see AOC being similarly intransigent - I expected better of her. But ...
2. Ms Warren, your work is not done. Until you frame your platform in simpler terms that we short-attention-span voters can grok in a sound bite, we (and Republicans) will still believe that you hold a radical far-left position. You need to work on that.
9
Others weren’t capable of a rational strategy either and now we have Social Security, Medicare and weekends.
3
@MikeG
Maybe you can help Paul out; were 'n when has Sanders said he won't negotiate on M4A? Show a quote with "all or nothing" from his lips if you'd be so kind.
Warren has given away an advantage in bargaining. She blinked and folded. They called her bluff and she capitulated. She now plays with "options" as the bargaining chips. Incremental, band aids and duct tape with lots of profits for the Insur. corps. The status quo.
Thus the huge bump in med. stocks the day Warren tucked tail and bellied up.
Intransigent...? On somethings (HC) everyone should be. Question is, why are so many not?
By the by...I wonder if Sanders being rated as the most truthful, trustworthy and honest, by Indies, Repubs and Dems. has anything to do with his supposed intransigent and obstinate demeanor? Wonder if he has earned this moniker because he fights for US. A politician that is honest, obstinate and fights for me? And has for decades?~! FINALLY~! Sign me up.
2
@Dobbys sock Let me turn your challenge around: please find me an example of any instance in which Sanders understood that his position on something was wrong or going to cause a problem, and he accepted that and made the appropriate adjustments. If you can't think of anything where he may be out of touch, take a look at his positions (past and present) on gun control. The only thing he's done is to lay low and try to not attract attention to his odd position. I don't think he's anti-gun-control or pandering to conservatives, I just think he's got this quirky feature of his beliefs, and he's not willing to listen to anyone on anything. In a word: Sanders has shown that he's not open-minded enough to be a good president.
Yes, Warren was smart to take this tack. Medicare for all cannot be achieved overnight.
But it looks like she is backtracking. So politically it doesn’t play well. The one blessing is that it is so early in the race. By next fall this will be her established position. It is the position that voters just tuning in will identify with her. News coverage changes so quickly. Who except brainwashed Republicans remember all the drama about her family stories about Indian heritage ?
I really hope she can win. The country would be so much better for it.
5
@Ex New Yorker
It is frustrating that tweeking or adjusting a policy position is so often portrayed as "flip flopping",or sometimes pandering. There is quite a difference between nuance and political expediency.
10
There’s no nuance for dying diabetics in choosing to go slow. This is life and death but some reduce it to a political horse race.
1
@Tim Lynch
You mean like Warren accused all the other candidates as they shied away from M4A?
She's eating crow, while attempting to say it tastes great and she meant to do such all along.
Tweaking or adjusting has all to often come to mean dropped and forgotten; please don't bring that up again, thanks. M4A has been set down (let down) by Liz.
Nuance? Lol... Not so much. More like drop it and run.
Political expediency...wind sock, fence sitter.
Pivot and pander.
Just good political machination sense.
Lets see if it works out for her.
1
About a third of America's health care expenses are already handled through Medicare, so if a partial transition is truly the gateway drug to cheaper drugs and healthcare in general, American's have been happily indulging in it for about half a century.
A medicare option is something else and has been correctly labeled a Trojan horse. If a lower price option is available to the consumer than private insurance, whether it be corporations seeking to keep down cost of health plans or individuals trying to stay within stressed budgets, the more efficient and lower priced option will eventually win out.
Which is why Lieberman heeded the call of his insurance donor base and defeated Obama's attempt to include this in the ACA.
The power of the insurance companies will likely make even getting the option through the gates a heavy political lift.
6
When I worked in the United States, I had generally good insurance policies. I have the same thing in Canada, except that part of the coverage is on the public plan, and part is on the private plan that my employer pays for. The private part is relatively small, and it’s not that expensive.
Private medical insurance in Canada is limited to a small part of the medical economy, where market solutions can function. I have the advantage of working in an office in a large city, where medical care is readily available and the chance of an employment-related injury is very low. From a risk-management perspective, it’s like insuring a concrete building located next to a firehall. You pay a lower rate because the chance of chance of an expensive claim is low.
It would be foolish to put the bulk of a nation’s health insurance in private hands, just as it would be foolish to entrust the national defense to mercenaries. But within their limits they can do a useful job.
10
@Global Charm
Seems like you’re satisfied with Canadian health care, having experienced the systems in both countries. But please, please specifically compare waiting times and rationing. You must have heard the hysterical screams about waiting forever to see a doctor in Canada. It can’t be worse than rural California.
We've seen an increase in our usual regular mass shootings lately. No reason to think this won't continue.
Who pays the hospital bills for all these shooting victims? Some of their severe injuries must be expensive. Who pays for their families' funerals if they die? What happens to the children they support? Do their families suffer financial disaster as well as loss of loved one? Where is the media on this horrific situation?
In many other democracies they have both strong gun laws, and health care for all. Imagine living in such a society. Fewer shooting victims and also no victims of a high-profit medical care system.
One would think this huge contrast on such crucial life/death issues would be prominently covered and discussed in our American news media. I've never seen it even mentioned.
If they don't tackle it, we must ask -- why not?
21
@Meredith
That is another reason all gun buyers and owners should be required to buy liability insurance for every gun and a liability tax on ammunition.
10
@Meredith
NYT has had several articles featuring survivors of shootings with their many surgeries and sequelae.
The NYT ought to compare the case of Steve Scalise with his taxpayer-funded health insurance, with that of another shooting victim with similar injuries, who has either no insurance or some Republican touted insurance, to compare the out of pocket costs they faced. It would prove eye-opening, I believe.
6
@CTMD
Great suggestion.
Let people keep their private insurances if they want it.
I don't think there is need for anything more outside of improving Obamacare and getting more states on board. Medicare is better handled when it is funded through the states and providers work with their state agencies.
All bureaucracy is anathema but local and states ones are preferable.
@Barbara we're paying one third of our income for health insurance on the private market because we are self-employed. $27,000 a year for two people with no health problems or pre-conditions. ACA is even more expensive- WE'LL vote for any help we can get.
7
Insurance works best if the pool is large. To really get costs down, we need a national system, if for no other reason as to have the largest pool possible. 50 different solutions is highly inefficient, and the quality of your medical care shouldn’t depend on your zip code.
12
@Barbara
Medicare is a FEDERAL program. If you don’t even know that, how can you possibly have an informed opinion on health insurance policy?
"The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform."
I am neither a health insurance specialist nor a Nobel laureate in economics, but, ... well, duh. And if anything, as a nation we have already backtracked from the original promises of Obamacare by eliminating the individual mandate (aka, the "tax") and the requirement that all states provide Medicaid expansion. So we need reforms just to get back to the 2010 starting line.
8
I find this argument persuasive. One of the little "inconveniences" of democracy is that people who disagree with you also have the right to do what they can to influence policy in accord with their values.
The fact is that the even the partial reform represented by Obamacare has been under constant assault from the GOP for almost a decade now, and the notion that this sort of opposition will recede to an extent that would enable the passage of Single Payer within the next five years is delusional.
Single Payer polls best when it's presented in general terms as guaranteed Health Care. But that support erodes as soon as you discuss its attendant details, such as the taxes needed to pay for it, and greater government involvement in the healthcare system. Many people withdraw their support when they find out that they'd have to give up their current insurance.
Deny Trump a 2nd term is a national imperative. In that context, embracing a policy that has no chance of becoming law and yet can be so easily demagogued is insane.
2
Often the opposing party takes the House in two years. We saw this as Tea Party Republicans took the House in 2010, and as Democrats took back control in 2018. Whatever doesn't get done the first two years probably won't happen.
1
In the year that I’ve been living in Israel I’ve been surprised to meet older women who moved here because they couldn’t afford health care in the US. That makes me incredibly sad.
23
@Retired Teacher
I have retired friends who moved to Mexico for the same reason, they could no longer afford to be Americans.
1
@Concerned Citizen Most Medicare recipients also need a gap plan. Those can be quite expensive.
Just "grandfather" the private insurance option. This would get young people in the system immediately. Older folks have the Medicare option anyway. People whose insurance lapses or if they never had insurance would be shunted into the public system. Slow boil that frog.
12
@Mhevey
"Slow boil that frog."
Brilliant! In about 30 years of studying US healthcare/coverage policy, I've never come across a clearer, more well expressed strategy.
That metaphor even beats the Brits' "eating the artichoke leaf by leaf".
5
Here’s a place to start the change: like Switzerland, the second most expensive health care system, require all health insurance companies to be not for profit.
Here’s another: require all health plans to charge premiums as a percentage of income. I’d put Medicare on this regimen too. There’s no reason the janitor should have to pay the same premium as the company’s CEO.
13
@Vasari Winterburg A friend moved to France many years ago, where he enrolled in their national health care plan. He paid his share of the costs nationally based on his income. If that is still the arrangement in France, that explains why their health care insurance plan is one of the very best anywhere. Here in Italy there is no such arrangement and the national health service suffers from underfunding. I think this payment based on income is an excellent idea.
12
@Vasari Winterburg ...how the Swiss operate their system should be explained here.
In other capitalist democracies, if they don't use single payer, they have insurance mandates---but with the crucial factor of govt regulation of insurance premiums.
Profit is not 1st priority. Here that would be portrayed as unAmerican.
Krugman, the economist, should explain how non profit insurance operates in other capitalist democracies.
And how come their politicians can run for office without big donations from big insurance and pharma?
Would that interest Krugman--- or someone-- to write about?
5
Question: How many people have to die from our broken health care system before our broken political system gets around to fixing it?
11
How many have to die before there is good health care. Only a dozen or so republican senators and one president.
1
@MTDougC ....same question for our gun laws...how many shooting victims have to die or be disabled, before our broken political system fixes it?
1
@Meredith Yep. Agreed, same root problem-corruption aka "campaign contributions".
1
I know that Elizabeth Warren has spoken directly to Paul Krugman about her health reform plan, so if he supports it, it is with understanding about the social, poliitcal, moral, and economic benefits it offers to our society.
I hope Sen. Warren gets the time to defend her plan during the Wed. debate and convinces others that it is a good plan with the right strategy to bring it to fruition.
6
Warren can easily pivot to a more popular position by pointing out that as President she could hardly dictate a change to single payer, that it will not pass until Congress is ready to pass it, and that Congress will never pass it until the American people believe it would be best for them. She has laid it out as a template for judging how close we are to really complete health insurance, and showed how we can pay for it without raising taxes on most Americans, but she is also dedicated to improving ACA until we get there.
9
Thank you for your definitive answer to the Warren sceptics. As lofty as her ideals might be she is a pragmatist and does give us our best shot of making something happen on this and other issues. Unfortunately, there are a lot of people in America who will be very sick or very dead by the time the second stage of the plan is implemented. There has to be some sort of emergency response to cover them between now and single payer. At the same time, the Feds must help the growing number of people whose hospitals have closed and whose doctors have left town. What is needed is a publicly funded American version of Doctors Without Borders establishing clinics where they are most needed.
8
@The Dog ....
Yes, a version of Doctors Without Borders, and a Marshall Plan----to bring America up to late 20trh century humane standards of other civilized countries.
America is unique---many people think that high profit health care is part of American Freedom, and the sick and dead are a worthy price to pay for it. Too bad if hospitals close and doctors leave.
Just like the bodies piling up from gun shot wounds are worth it to keep our gun Freedoms.
Our media commentators try to stay as 'centrist' as possible in our distorted politics.
Thank you, Prof. Krugman, for being the best regular op-ed columnist in the mainstream media when it comes to understanding just what Elizabeth Warren is up to. I fully agree with you that moving in one swell foop (sic!) from a flawed ACA to single payer is not feasible, and that while single payer may prove to be the best way we can provide universal access to quality health care regardless of how much money you have, it is not necessarily the best way for the United States. So some form of flexible gradualism is in order, and Elizabeth Warren knows this and you acknowledge that she knows this. Changing any established regime is always hard, and there will always be some false steps requiring correction (such as Obama abandoning the public option rather than face Joe Lieberman down). Warren also recognizes this and her plans reflect it.
Warren's understanding differentiates her from Sanders, who seems to have his eyes on the ultimate prize and no taste for the details needed to get there. It also distinguishes her from Buttigieg, who sees a feasible small step but does not place it in the context of a larger picture. And it certainly differentiates her from those who believe that they need for support from an extinct species--namely moderate Republicans--in order to have permission to do anything.
18
@beaujames ....you must have excellent, secure health insurance that you can well afford. Congrats.
But what about all the people who can't afford HC, and will die, or be disabled, or leave their families with financial devastation?
Read NYT op ed -- The Fake Freedom of American Health Care, By Anu Partanen
'flexible gradualism'? How many years, how many election cycles? 2024, 2028? What's the price we have to pay, meanwhile?
We see through our media columnists who stay safely centrist in a political culture that is badly distorted, and doesn't serve the voters.
1
@Meredith,
I have Medicare. Don't congratulate me for that. My eyes, ears, and teeth are not covered. You recommend some reading for me; I recommend that you reread Prof. Krugman's article and Elizabeth Warren's proposals. FWIW, I have dozens of publications myself on this topic, including comparisons of different countries, but that's not my point.
It is important that we get to universal access to healthcare coverage without regard to ability to pay as soon as possible, but getting to that state as soon as possible doesn't mean demanding my version of all or nothing immediately, because that risks getting nothing now or soon. I'll take a public option right away as a start and then move to getting it better by regular improvements. No country except the United Kingdom when Clement Attlee succeeded Winston Churchill did it all at once, and that was immediately post WWII, and even then suffered growing pains with regard to quality of care for a long time.
@beaujames
UK's conservative PM Thatcher supported and was proud of their NHS.
Compare to our GOP aiming to destroy ACA, even though ACA supports private profit insurance.
The many countries starting HC for all in 20th C, --Canada in the 1960s, etc---- had the basic requirement of the right to HC, no matter a person's income, job status, heath condition etc.
The US basic requirement is 1st to satisfy insurance profits---sold as American Freedom from Big Govt---and then try to get more peole insured. And let states do what they want.
Very different from other capitalist democracies.
Paul, I think the surest path to a system of "Medicare for All' is to give people the option to buy into Medicare if they want to. Mandating it will only generate resistance. Private insurance companies can't compete with "Medicare for Those Who Want It," and they know it. Let market forces bury the private insurance industry. Elizabeth Warren is smart to realize that "Medicare for All" will not fly given where we are now. But if she'll fight for the option of allowing people to buy into it--and believe me, she will have to go mano-a-mano with the private insurers--then we will be on the road to a cost-effective health insurance system that covers everyone.
7
On Sept 3, 1967, at 4:50 am, Swedish drivers shifted from the left to the right side of the road. They did not have a shift to the right for those who want it, they went all in.
This might be a stern comparison, but it often makes sense to change all at once.
13
@Drjohnhodgson
It certainly makes sense not to give people the option of driving on the side of the road they prefer. Not sure that approach applies to the transition in health insurance.
7
It does. Unfortunately getting Americans to all go in the same direction is like herding cats, some will run the other direction just because they can.
2
In Sweden.
I'm 59 and was just permanently laid off. I cannot wait for incremental change, I will be broke or dead by then.
16
@SteveH
If you can get good coverage under ACA for little or no cost because your income is low, with an option to get into Medicare or not, it is not incremental for you, it's a radical difference.
6
Obviously, a single-payer system is best. That's why sensible developed countries adopted it decades ago. Just as obviously, a great many Americans, heavily propagandized by the insurance and health-care profit-takers, are frightened of substantive change.
So a gradual approach is required. Give people the option to switch to a lower-cost public plan that still gets them covered, and many will switch. And then their friends, neighbors, and family members who are still getting gouged under for-profit plans will hear about it. And also switch in time.
Piano, piano, as the Italians say. Little bit by little bit.
7
Did they now. No, actually, they did not.
They adopted UNIVERSAL coverage, which is not the same, and achieved by severl very different routes.
Please learn the words.
1
Some years ago 31% of the cost for insured Montanans went to pay for the uninsured who primarily utilized the emergency room for care. Providing finances today for care continues to be complex , but I know that Trump and the Republican insistence on destroying environmental laws created to protect our health and their turning their backs on common sense gun legislation have tremendous financial and tragic costs.
6
Do Americans just have to keep hoping, asking--- Oh, please, pretty please, can’t we have guaranteed healthcare like millions of citizens in other nations enjoy? And they’re also capitalist, too.
No, not yet? Ok, we'll wait. Maybe someday. Gosh darn. So we'll just wait for 'stepping stones for something bigger' Great line, PK.
How many more election cycles must we wait? What excuses will parties and media pundits think up in 2024, 2028?
"How long, Oh, Lord, how long?" Dr. King asked, at the Lincoln Memorial.
Hooray---some states had "steep drops" in uninsured! But dozens of countries have for generations had NO uninsured citizens. Would economist Krugman ever be interested in analyzing how they manage what the US can’t do?
We’re manipulated to be thankful for ACA but we still have 37 million uninsured, and millions more struggling with high medical bills. Who pays the hospital bills for all those gun shot victims on the news every day? Profit off of our sickness is equated with "Americanism".
Too many voters are conditioned to define policies in the public interest as "left wing/big govt" taking over our freedoms. It's one of the great propaganda cons in any democracy, and it's worked. Our political 'center' can't serve the true public interest.
Warren and Sanders at least had the guts to start setting a new standard, even if they don't get the nomination. To future politicians-- start building-- to liberate America---to achieve progress and equality
13
It would help if the corporate media, which sells a lot of advertising to the health care-industrial complex, would not keep routinely describing Medicare-for-All almost exclusively as an immensely costly plan to "take away" the current health insurance of everyone under 65. In what alternate journalistic universe is that straightforward, honest, fair and balanced reporting and not mostly just selectively repeating talking points from health care lobbyists and GOP operatives.
47
She proposes no private insurance, which is not a desirable outcome for many in this country.
6
@DM Hey, it's a "free market" and if people want, they can pay doctors privately. They do in Europe where there is more universal health care coverage.
4
I know of absolutely nobody who is in love with their private insurance company. Their providers? Sure. But not the paperwork shufflers and bureaucrats.
15
I agree with your counsel at the end of this essay, but I offer further counsel that I don't really think the Democratic political candidates have done a good job of defining the problem we have in our healthcare system and in the inadequacy of the insurance coverage. Eventually, to reach a good solution and a plan for implementing the solution, our political candidates must make a persuasive case that will win over a clear majority of the voters and a majority of the lawmakers.
I am reading and listening to what they are saying and writing but I feel like they are short of the mark. I also,I think the NYTimes could help by using its graphics talent to describe the demographics of our health system and how our healthcare system compares with other economically advanced countries.
There is a lot of negative propaganda being printed about single payer, medicare-for-all, the ACA, etc and the fraud and waste in government public insurance programs that must be overcome. We have the data but it appears that we are not using it to define the problem or approaches to solving the problem.
It seems to me that somehow a cloak has been thrown over the data and this must changed, if we are to reach a national consensus on what we need to do.
14
I worked for 25 years and had excellent health care benefits from my last employer. At most, I spent $2500/year on deductibles, co-pays for prescription drugs, and visits to specialists; vision and dental coverage was included. My payroll contribution to the policy's premium was minimal. You can't beat that!
I'm on Medicare now. I spend an average of $9,000/year on premiums and prescription drug co-pays. Medigap premiums alone increase by 10% or more each year. And, there's no vision or dental coverage. Medicare-for-all? Hmmm?!
5
@RPS I'm on medicare and pay a fraction of what you pay. $2000 for premiums and a bit of out of pocket. But I am healthy, not on expensive drugs, rarely go to a specialist. In 2020, I will move over to an Advantage plan: $0 premium. You should try it.
8
@Repat Yeah. I pay more for Medigap because I'm high risk and have high prescription drug co-pays. Part D plans... ugh. I have Original Medicare A & B because there is no provider network and I can choose any primary doctor/specialist/hospital. Some Medicare Advantage plans have $0 premiums but there are other out-of-pocket costs that'll likely hit you. But, it sounds like you have good health on your side. Good luck.
4
@RPS Well, you prove the point that a more nationalized, controlled and fair-priced system needs to be implemented.
4
Krugman provided the less useful contrast. Bernie is NEVER going to be the Democratic nominee and the "full Bernie" of immediate and mandatory single payer ain't going to happen. I'm happy that Warren--would could be the nominee--is no longer declaring "I'm with Bernie" but has gone "two step". However, what I really am interested in is how her plan compares and differs from the public option plans of other potential nominees such as Buttigieg and Klobuchar. Love a future column discussing that contrast.
9
Like today's "moderate" Democrats, Obama went into the health-care debate proclaiming the importance of a public option. Like them, he also brought the delusion that the insurance & drug industries, and the Republicans, would be willing to work with him.
I don't see how we'll move forward politically without being honest: the industries that extract profit from health care are the enemy. They extort money from the public & use it to wield political power. They are not going to allow a "public option" or a "medicare buy-in" if the political winds are blowing toward a Biden or other "moderate."
34
@Martin: It is blatantly dishonest to claim that the Electoral College and Senate apportionment deliver anything resembling equal votes for all democracy.
1
If Warren requires W2s to show the amount employers pay for health insurance, maybe more people would wake up to the fact that it's incredibly expensive and doesn't have to be that way. Your "great" and "affordable" insurance is probably costing your employer $20k/year. Given that the median wage is $31k, that's quite a tax.
18
@SAO
My W-2 and my wife's W-2 have always shown the employer's share of my health insurance costs.
Does yours not show this?
1
Many employees receive the 1095C form, courtesy of the ACA.
1
@MidtownATL
Correction: I have always seen the employer's share of health insurance costs on my paystub (not my W-2).
But I thought that information was widely available to most employees already.
1
I know of a recent case where a young person died because they stopped taking their insulin because they could no longer find a way to afford it.
I don’t know this person. This is a third-hand account. I am very shaken to hear it.
I am saying it out loud because it happens.
Here. Today.
In the United States.
One of Warren’s first Executive Actions would include the government’s legal right to manufacture a drug as common as insulin should the need arise when the market fails and real American lives hang in the balance.
This is just one of a few incremental steps Warren proposed that would go so far to help so many.
Why is there ever a shortage of tetanus shots or IV fluid? That is so crazy!
If Warren named her initiatives as “pizzazz health fun”, she’d win?
What if she vowed to use a fancy glitter gel pen instead? That dazzles, no?
18
I work at an animal hospital and the shortages hit us too. We had great difficulty finding IV fluids for a while, the staff who does purchasing spent a ridiculous amount of time hunting them down. The IV fluid manufacturing was being done in Puerto Rico & when the hurricane hit that caused a shortage. Not smart to put all production of something so vital in one place but that’s what capitalism does. Everything goes to the cheapest place, because making money is the only thing the manufacturers care about.
4
My local hospital authority has just gained approval for a $250 million expansion. The hospital board has assured the city council that bonds for the project will be paid by hospital revenues, not public appropriations. But we know how that works: having augmented the facilities, the hospital will have to increase use to drive more revenue, and of course rates will never fall. The project is said to reduce costs by encouraging efficiency, in the form of reorganizing departments under a single administrative umbrella.
What no hospital administrator wants to hear is that Medicare-for-All would bend the cost curve down by simplifying billing. Rather than employing legions of staff whose job it is to bill the dozens of insurance plans, hospitals would essentially bill a single payer. And of course that single payer could force prices downward by putting an end to $10 aspirin or $30 bedpans. We might again see hospitals as centers of healing rather than palaces with interior waterfalls, marble lobbies, concierge services.
50
@Ockham9 Stanford [Palo Alto, CA] Health's NEW Hospital just opened yesterday - at a cost of about $2.5B. Granted there are quite a few 'donations', yet this is another reason why I will try to shift away from this hospital and its clinics. The hospital-affiliated clinics charge 'emergency-like' rates because they have the 'facilities' to take care of complicated cases - whether one needs that care or not the overhead is factored in to the pricing.
13
Amy Klobuchar and Pete Buttigieg have called for not requiring people to give up private insurance. I’m glad Elizabeth Warren has clarified that she also wants to make incremental change. We will get to single payer eventually, so long as people have the option to *choose* to give up their private insurance in favor of something better. We can let market forces take care of getting us there. On the other hand, if we try and force people to do what “we know is best for them” we may end up with nothing.
10
As long as healthcare provides can choose to treat patients able to pay more, they’ll do that. People on Medicaid can barely find doctors in many states. We will never have a single-payer system that won’t allow folks to opt out.
1
@Jeanne Lepowsky: Private insurers want the government to take over all pre-existing conditions.
Of all the naifs in the Democratic race, the youngest is the most naive of all.
2
@Jeanne Lepowsky: Single-payers have to raise the money to pay for care one way or another. I think such plans should be funded by a value-added tax that makes the public cost of the system obvious to all, to discourage abuse.
Let's also keep in mind the Republican healthcare plan, which includes maintaining the Great American Healthcare Rip-Off where half a million Americans still go bankrupt each and every year thanks to the world's biggest healthcare scam, 'for-profit-and-for-shareholder-healthcare, a.k.a. Blood Money, Inc.
America's healthcare prices are overpriced by at least $1 TRILLION each and every year.
That's the amount that our 17% of GDP rip-off system exceeds the cost of healthcare in every other rich country.
Switzerland 12.4% of GDP
Germany 11.3
Sweden 11.0
France 11.0
Japan 10.9
Netherlands 10.5
Norway 10.5
Belgium 10.4
Austria 10.4
Denmark 10.4
Canada 10.3
UK 9.7%
That extra $1 TRILLION-plus annually sloshing around America's insurance-company middlemen, hospital corporations, pill-pushing PhRMA companies, medical supply extortionists and corporate blood-money shareholders is enough to give Americans the finest healthcare in the world AND a giant rebate to everyone instead of giving us the biggest rip-off in the world.
The money flows simply need to be reconfigured away from corporate profits and from insurance middlemen scam artists and back to the human health of 320 million Americans.
Many Americans - with and without insurance - skip the doctor because of medical sticker shock.
We may have to take an incremental approach, but it's sad when the evidence of better systems are staring us in the face from every other rich country.
Wake up and smell civilization, America.
422
@
You're right on the money, Socrates. One of the most disquieting aspects of the platforms of Warren and Buttegieg, perhaps somewhat seconded here by Krugman, is the assumption that providing universal coverage is going to cost more money than the present system. This assumption in turn is based on a flawed estimate of costs by the Urban Institute, amplified by the Heritage Foundation and by other elements of the right wing echo chamber.
Buttegieg's estimate is 33% of GDP, Warren's is 26%. Does this make any sense given that Switzerland, a rich country which covers all its citizens to a high level, does it for 13% of GDP, or is America uniquely incompetent?
We calculate that the US can cover everyone to a high level for 13% of GDP, the same as Switzerland. Buttegieg's idea of Medicare-if-you-want-it is the correct tack for Democrats, just get your numbers straight, Pete!
16
@Socrates
Single payer government program advocates might propose that the national budget for health care services be capped at 12% of GDP. If your reasoning is correct, that should provide plenty of money to pay for all the services Americans need. It would also prevent the budget creep that is all to common and which would destroy the plan's promised economic benefits.
8
@Socrates: Administrative overhead in health care is America's biggest make-work project.
10
One thing rural & urban voters share is a need for affordable healthcare. The difference is most urban hospitals aren't closing and many rural ones are. Urban voters can find specialists and rural voters not so much.
Second, rural voters know what preexisting conditions are. Both are realizing that after more than a decade the GOP is not united on anything except taking healthcare away from folks. They will never fund high risk pools.
I doubt we are capable of medicare for all even though the numbers work unless stupid people run them. The developed nations do it for about 9% of GDP per capita and we spend 18%. That said if you have private care you don't want to give it up.
So do a public option and work your way to consensus. It's a winner for urban and rural voters. Give them a reason to vote democratic in 2020 and healthcare is that reason.
8
High risk pools are a terrible idea. They have never worked well.
3
@Donald Pack: Americans are too poorly educated at science to follow doctor's instructions.
Warren was insistent that Pete's Medicare for All who want it was "for all who can afford it," in the last debate.
She said that anyone who permitted individual choice in the matter was an Enemy of the People.
Then her polling numbers began to drop. She realized that she might not win the nomination if she remained true to her beliefs.
So, in the interest of winning, she did an about face.
All of a sudden she became a major champion of giving people the right to hold onto their private insurance.
Her minions and acolytes are now defending this decision as real politik, the end justifies the means.
I call it hypocrisy.
If she can totally adopt the indefensible, according to her philosophy of government knows best, then what else will she change?
Understandably, the Bernie crowd feels betrayed. She stabbed them in the back and now wants them to support her when Bernie falls by the wayside, as he will.
Warren's team has let it be known that they expect the Bernie team to pull out and hand her all their chips so that she can finally coast to victory.
Fat chance.
If I were a rabid Bernie/Warren supporter I would feel betrayed.
I find it very revealing that so many Warrenites are happily supporting her change of heart.
Tune in on Wednesday to watch her defend the indefensible.
She is looking less and less presidential each day as her movement begins to collapse and she grasps at straws.
4
@Simon Sez: Medicare for all who want it is a gift to insurance companies that don't cover pre-existing conditions.
6
@Simon Sez
"I call it [Warren's changed proposal] hypocrisy.
No.
She's a pragmatic legislator who presents a thought-out idea clearly and responds to the reaction it gets.
If sudden change gets a bad reception, she'll try gradual change with a timetable.
The point is:
She's conscientiously working towards the goal of providing healthcare affordably for the American people, which will involve phasing out the over-the-top profiteers in the medical marketplace.
Which is a really good thing. We don't want to get lost in the weeds here.
We want to move into an affordable healthcare system that works and it will take some time.
Evolutionary change versus revolutionary change. Evolutionary change may be slower, but will bring less pain and likely a better endproduct than the revolutionary approach. The added benefit of showing how people’s lives improve with the evolutionary change would help persuade further changes to enable more (hopefully all) to get healthcare.
4
Many moderates claim to believe that single payer would be the best system, yet they continue to tell us that it’s bad politics.
They’re wrong.
In fact, they’re incoherent.
If you can’t persuade voters to support the best plan, what makes you think you can win them over with a lesser one?
8
Voters do really stupid things sometimes, look who we have for a President! They often vote against the best thing for themselves. It shouldn’t be so hard to get people to vote for their own interests.
1
@Smilodon7o This is a great reason to keep things simple. We shouldn't confound matters by campaigning on positions we don't believe in.
How long is your eventual single payer timeline? Ted Kennedy proposed a more radical version in the early 70's .akin to the English socialized system of today. The ACA is in many respects a version of the Republican alternative to Clinton's Health Plan in 1993. The ACA for many is not that affordable. Virtually every one in the ACA pays a greater fraction of their income, sometimes exceedingly, more than what you pay Likewise with many people on private insurance, not to mention the uninsured. Health care should have no relationship to income.
Democratic victories in Virginia and Kentucky had nothing to do with moderate health care policies. This is a pundit myth. In fact, in the Trump states where incomes are lower and health costs per an individuals income is higher, a single payer system could be quite attractive, But those who play liberals like yourself are doing the initial stage of downplaying it, to be picked up by a more vitriolic stage by the Republicans. Let the issues of M4A be explained and debated honestly, something which the MSM is not doing.
The idea that Warren's phase 2 will retreat into some distant future seems to be agreeable with you. Remember we spend 18% of GDP on health care, and its is creeping up further. Only a Single Payer like systems existing in numerous countries have been successful in reducing these costs . Climate change, affordable housing and other pressing issues will not be solved will not be solved without M4A
4
@mbaris1
"Virtually every one in the ACA pays a greater fraction of their income, sometimes exceedingly, more than what you pay Likewise with many people on private insurance, not to mention the uninsured."
Wrong. Not in my - or in anyone else I know -personal experience with the ACA.
Not good to work with bad information.
2
Untrue. I pay a lot less than when I had private insurance. That is, before I was declared a preexisting condition and denied insurance completely. Thanks to the ACA, I have it now.
4
@atutu
I said the fraction of his income is a lot less
than the fraction of the income on someone on ACA. Let's say that his income is 300000, undoubtedly he has private insurance, and say he pays 3000 out of his pocket. Compare that to someone on the ACA with the best subsidized plan earning 20000, probably paying at least 800 or so in premiums and a additional 2000 in responsibility for deductibles. There is no question that the fraction of his income paid is less than the ACA person. For those with with less subsidized plans or no subsidies, this is more true is more true,The person on ACA who has some symptom that his doctor recommends an expensive diagnostic exam which he must pay out of his deductibles is less likely to follow his doctor's recommendation. When you make 20000, 800 or so is significant. Health care should not be based on income.
The ACA may be better than private insurance. But Medicare For ALL is better than private insurance for everyone, including everyone on private insurance. This is fundamental.
There is another way to implement a single-payer system, one that validates the ‘choice’ and ‘freedom’ that Americans say they want. It’s basically the approach advocated by Saez and Zucman: make Medicare-for-All the default option, but allow anyone who wishes to opt-out of the program. There would, of course, be financial consequences for doing so. Under the Warren plan to fund the program, employers would transfer the funds they currently pay to insurance companies for their employee health benefit to the federal government, to partially pay for the public program. The government would calculate the per capita cost of Medicare-for-All, and send back to the employer that amount for each employee who elected to retain private insurance. If the two premiums — public and private — were equal, employees would see no change. But if private insurance cost more, the employer and employee would negotiate how to pay the balance, through an additional employee contribution, foregoing salary increases, or cutting elements of the insurance coverage. My guess is that after two years of this, we would see more and more employees realizing that their private plan wasn’t such a good deal after all.
5
Obamacare was the greatest political catastrophe in this nation’s history. It led immediately to the loss of Dem control of the House and Senate, of governorships and state legislatures, and ultimately led to the election of Donald Trump. The Dems would still be losing elections if Trump had not managed to repeal the individual mandate. The availability of health insurance is useless if you cannot afford the premiums, co-pays, or deductibles, and we are talking about at least 40% of the population, namely those who cannot cover an unexpected $400 expense without going into debt. At least now those people have the option of going uninsured without having to pay a penalty to do so.
The liberal economists who brought us Obamacare and who now hope to bring us some other misbegotten substitute should the Dems regain power in 2020 are a greater threat to this country’s social fabric and economic well-being than any of Mr. Trump’s outrageous antics or excesses. Expanding Medicaid and subsidizing pre-existing conditions is all that is necessary or desired. We do not need the advice of any economists to accomplish this. In fact, there is no area of public policy where we need the advice of economists at all.
1
Except all the ones where you have to know the numbers, and human reactions to the numbers. Neither of which you have an earthly about, and in fact appear to be violently allergic to.
3
@kbaa Remember, the ACA is a modified version of the conservative, Heritage Foundation plan from the 90's. At that time, even they wanted to mandate coverage. Funny how people forget how things happen.
4
So where’s super genius Trump’s better, cheaper plan? Nowhere. And merely subsidizing people with preexisting conditions won’t cut it. They won’t sell you insurance for ANY price. The companies DO NOT WANT YOU. They do not care one bit about you. They won’t even quote you a price, they just say no!
1
Until the special deals that exist within the US health system are eliminated it will not be possible to fix the system. The current system is the worst of socialized medicine for the poor and elderly, accompanied by an expensive, government-subsidized corporate third party payer plan.
The health providers game the system and pass much of the bill to taxpayers, but line their pockets. Any attempt to use our leverage as taxpayers is scaremongers with the term “rationing”. We as taxpayers pay ransom so our poorer and older neighbors don’t die or suffer, but the health industry exploits this situation for obscene profits.
We need to withhold our public dollars from their bloated system until they are willing to deal. Let them try to collect those payments from those indigent patients on their own if they love the free market so much.
3
@Jazz Paw: This ridiculous system spends more on prescription drug advertising to dope the media than on research. And what research it does is on palliatives, not cures.
One of Krugman's best, especially in saluting Nancy Pelosi's efforts to get the ACA passed and reaffirming what she meant. In his debates with Clinton, Sanders made it clear that the ACA should be replaced by entirely new legislation. The current candidate who has consistently supported improving and building on the ACA is Biden.
3
I'm glad Warren has spelled out her transition plan, giving a government funded health plan three years to prove itself.
On her website elizabethwarren.com/plans she has a section on executive actions, not dependent on Congress, by which a President Warren can reverse every action Trump imposed on the ACA. So that answers the problem of getting some of her plan through, even if the Senate doesn't flip.
Sanders plan, as I read it a few months ago, would take four years to realize as he would roll back the age eligibility in four increments. He provides several choices for how to get to Medicare for All, but has not spelled out which one is his.
Between the two, I think Warren has the safer, incremental plan that would not force people off of private insurance but, instead, woo them to her improved, less expensive health plan.
5
Medical care should not be a for-profit industry. Period.
Paying dividends to investors or paying all ultra high salaries - which are paid for by denying people health care - should not be acceptable. But here we are.
Why must this conversation be so difficult, and politicians have such a hard time "selling" something better than this to public?
35
The only problem with MFA is that the MSM (including the NYT and Mr. Krugman) keep fighting against it using talking points from the insurance and pharmaceutical companies. There are no facts in these points, just fear-mongering geared towards raising the anxiety of Americans who are already scared and confused about their health care and insurance coverage.
But what if they could have a system that didn't require them to be insurance, medical, and legal experts to understand it? What if they didn't have to try and figure out whether they can afford a needed operation or medication? What if they could just go to their family doctor or specialist and get treated without waiting for pre-authorization, and then not have to worry about the co-pays, out of pockets, and uncovered amounts that might bankrupt them? Do you think Americans might be interested in a system like that? You betcha!
But to get there means taking a big jump - from a for-profit system to a non-profit one. There is no middle ground. Either the system is dependent on private insurers, which requires a profit mechanism as part of it, thus inflating costs, and causing all the other problems noted above, or it's run by the government and requires no profit, and doesn't have the problems and expense of our current system.
You would think that smart people like journalists could understand this, but apparently not. Or maybe they have a different agenda? Regardless, use facts, not fear-mongering please.
18
And do you actually believe that you just used facts?
My, my, my.
The polls, recent election results, surveys, experienced politicians are all pointing toward the same conclusion. Which is, nominate a moderate who will enact incremental improvements. The issue is not what will work best but what is an improvement that is palatable to enough people to get Trump thrown out of office.
Medicare for all my very well be the best and ultimate solution, but that does not make it the most politically expedient. We are in the political realm, not physics. Whatever is proposed must sway a sufficient number of voters to enact a regime change. (In the case of Trump, regime is more accurate than administration).
Mayor Pete is rising in the polls for this very reason. He had it right from the start. Voters need to get real and stop chasing after dreams and start reaching for what they can get their hands on.
Besides, our healthcare system has grown into such a behemoth of inefficiency and waste, that it's going to take decades to unravel it and set it straight. Let's do what we can do now and keep working on fixing it as we untangle the mess.
22
@Bruce Rozenblit
At the start, he was all in for Medicare for All, so in that sense he did have it right from the start. Then his donors and advisors got ahold of him, and now he's singing a different tune. I remember during another presidential campaign, that was called a flip-flop.
6
@Bruce Rozenblit
In the interim what happens to those who still have no coverage or inadequate coverage. Are they not worthy?
1
Sanders is calling for a revolution. So it is easy to see why for him it is Medicare for all from the start. Incrementalism and revolution don't mix. Warren seems to be taking a big risk in losing support from progressives with her two-step plan. And since generally the party of the president loses seats in mid-term elections the chances of passing Medicare for all in her third year as president would probably be much worse than during her first year. If she wants to give up on Medicare for all during a first term she should be honest and say so. I would be pretty skeptical about her new plan which seems very unlikely to produce Medicare for all within a four-year term.
3
Our healthcare is so expensive here in the USA in large part because we seem to be actively trying to kill ourselves : we gorge to obesity, which leads to degenerative arthritis and diabetes .... which leads to kidney dysfunction and heart disease and hypertension and stroke and heart attack.
We are a mess, and we don’t deserve taxpayer-subsidized healthcare until we commit ourselves to personal health basics.....Which are, as we all already know: eat enough minimally processed calories to maintain a BMI 19-28 (depending on your build); exercise 30+ minutes per day; don’t use tobacco or illegal drugs; drink alcohol only in moderation; sleep 7-9 hours per night.
Let’s start there.
3
That’s easy to say, but much harder to actually do. The healthiest food is often the most expensive and often isn’t available to the poorest. And it’s hard to think about exercise when you arrive home from work exhausted from your second low wage job that you have to have to afford rent in this country.
4
@GBR Have you decided on what color our uniforms should be, and long or short sleeve yet? I do apologize for being late in my response, but I assure you I have signed over to you, and forwarded the Deed to my house, and all other liquid assets will follow, ASAP......
I'm a US physician who supports universal health care. I have mostly worked in the US but have also worked in Australia and currently work in New Zealand. These two countries have guaranteed government supplied healthcare for everyone with an additional private components available to those who want added benefits. Both countries spend roughly 9% of GDP on health care (compared to nearly 18% in the US) and both countries have good outcomes. No you don't get the fanciest chemotherapies or surgeries and sometimes wait times for elective surgeries are long, but the general health of the countries is maintained very well. These models would both work well in the US and would be more appealing than simply Medicare for all and banning private insurance. The key to making this affordable is price control. Health care is by nature an opaque market, and I can tell you there is vast profiteering in the US system that simply doesn't happen in other countries because there are price controls. Everyone involved in health care in the US would need to make less (including doctors like me who are probably overpaid) but the gains to our public health and economy would ultimately be much greater.
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Everyone involved in health care in the US would need to make less...
The part nobody seems to get. This is how it works, folks. This is what everyone needs to understand. There will be pushback.
7
@SteveH You are exactly right. There will be push back from hospitals, from medical specialists, from device manufacturers, from drug companies and from insurance companies. And, there will be push back from at least 40% of American opposed to single payer on ideological grounds, along with another 10 to 20% who would want Medical for All if it already existed, but are afraid of losing their current benefits. There will also be physicians who will decide to go private pay rather than accept government price controls, exacerbating physician shortages in some areas. Medicare for All is great in principle, but just because other countries have single payer does not mean it is achievable in the United States. We can get Medicare for All after a complete breakdown in U.S. health insurance. We are getting close, but we are not there yet politically. Incremental change is the politically realistic and the moral path to universal coverage. I have worked in health care research for 40 years and have watched single payer advocates crash and burn since grad school. It is simply more difficult to get to single payer politically than folks understand. The votes in the senate are simply not there, and will not be there even after a wave election in 2020.
3
@ChinaDoubter " No you don't get the fanciest chemotherapies or surgeries and sometimes wait times for elective surgeries are long, "
Many with private insurance that is good, fear that their standard of care will end up as a 'wait game' and lesser health care than they had on private insurance.
I believe that until that issue is fully discussed, those with really good private insurance will never fully come around.
So, an explanation from you how not getting the best chemo and surgeries available work into this greatness of Universal Health Care that becomes free through taxation.
Wait time for elective is doable, but Stage 4 cancer waits for no one and seeking the best treatment is optimal for living.
I am guessing that the free with it's costs constraints doesn't allow for the more complex treatments?
2
I like Warren's new proposal--but can't help but note that Pete Buttigieg got there long before her. In any case, I think Mr. Krugman is correct, in that an all-or-nothing approach gets nothing. I would like to see, as a first step, Medicare at 62 for those who take Social Security at 62. (It makes little sense to offer half of a safety net, as we do today.) Certainly, I would like to see a single-payer universal plan someday, but we have to walk before we can run. Fortunately, Obamacare at least got us crawling.
23
The power of the lobby can overcome the will of Congresspersons. Going too far, too fast, will engender pushback and failure. That could only occur when POTUS and both houses of Congress are under one party that is more united than they are today.
2
Great analysis and common sense, on how we can arrive at the healthcare system we want and need in incremental steps.
“We have to pass the bill so that you can find out what is in it.”
This was the first time I have heard any columnist rebut the Republican's spin of Pelosi's statement.
5
The ACA was truncated (not creating a federal universal enrollment everywhere to supply meaningful competition in the market place) in order to get it passed. It was always a first step to be followed by more steps to remediate the present unsustainable course of runaway insurance, drug, hospital, and physician costs. The GOP sabotaged those next steps with no real alternatives. Mitch Mc Connell's statement that his goal to make Obama a one term President polluted the Republican Party's ability to govern that has morphed into the present situation of a dangerous existential crisis for the U.S. Republic.
The health care crisis is the metaphor of how not to run a country. And this metaphor has other applications that have become truly frightening.
11
Successful reform of healthcare should include a public option -- the Medicare for All Who Want It. That will be the precondition for single payer that Mr. Krugman hopes for. Unfortunately, he again fails to explicitly state that he favors Medicare for All Who Want It and continues to criticize Medicare for All.
1
@OldBoatMan: Krugman stated, in the last line of his article: "...there is a good case for eventually going single payer." That would be tantamount to Medicare for All.
6
@Elin Minkoff Any successful two step reform of healthcare must include a public option. Americans must be able to choose a new plan. Their employers must have the option to subsidize public option premiums for their employees who elect the public option.
The omission of a public option set the ACA up for failure. It is now on life support.
My criticism or Mr. Krugman's column is that he fails even to mention a public option let alone make the point that a public option is necessary if we hope to move to a single-payer, universal healthcare system.
People ask how will we pay for Medicare for All.
We already are paying for it. We just aren't getting it.
We spend $3.5 Trillion on healthcare.
We spend $11,000 per person - twice as much as the other first world countries.
We spend 18% of GDP - twice as much as the other first world countries.
They have some form of universal healthcare.
We have parts of the US with infant mortality rates of a second-world country.
All the money we pay to private insurance companies would go to Medicare for All. And we would save money.
And we wouldn't have to argue with our insurance companies.
And we could change jobs without worrying about our health insurance.
You would think corporate America would be for it. They don't want to be responsible for employees healthcare.
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True Corporations ( as sentient beings) don't love managing health insurance benefits for employees. They do how ever love the tax cuts associated with their cost of a benefit calculated as part of compensation. if a single payer option ever happens, one wonders whether employees would suddenly get salary hikes commensurate with the health insurance premiums?
1
@Independent: Corporate America---the part of corporate America that comprises health insurance corporations, and big Pharma, etc. definitely does NOT want it! They would not be able to steal from American citizens as they do now, by raping them with high health insurance premiums, huge deductibles, and after you spend all that money, they slam you with denials of care, and we have the highest drug prices anywhere in the world. They want to keep things just as they are----they are rolling in so much money that does nothing to further or improve health care, but is just about greed. And they keep giving big "donations"
(read: bribes, kickbacks, payoffs) to the politicians who will keep things just the way they are! Lines the corporate oligarchs pockets, and lines the politician's pockets. As for you, Americans: These practices keep you running like crazy, but you never catch up. That is exactly the idea.
3
Critical is the public option - being allowed to buy into Medicare. This would shift pricing power to MediCare and bring the US close to where, say, Germany and Switzerland are - countries that haven’t eliminated private insurance either, but where the price setting power of health care providers is being contained by a strong public insurance scheme that is open to everyone.
Medicare for all is neither necessary nor particularly desirable.
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Bernie Sanders will implement as much of it as he can. He would amend and negotiate if necessary, as all his political life proves he does well. As far as keeping both systems, to someone residing in another country, already living through where the US is at, its good in theory. But the practicality of it does not work the way its intended.
Leaving part private will ALWAYS allow room for that sector to gain ground again. All the Republicans need to do, is underfund the public system and prop up the private and you'll be back at square one, as my country will so unequivocally show you. Where i live is a place that claims to have free health care, but too long a reign of the neoliberals plutocrats, has decimated what was once a world revered system 30yrs ago. It's budget had been slashed so much over the years, the only way to get anywhere in the public system, is if your dying.
But those fortunate enough to pay for private health insurance and the thousands of dollars out of pocket get the best treatment the fastest. Does that sound like a "fair" system? Because that's exactly what having both is like in reality.
I've worked in the private health industry in Australia for 13yrs. I could argue both sides, but the honest truth is, no one, should be profiteering off people's health. If you allow for a small portion of private insurance, it will still always be lobbying for more more more..... Always.
14
I think it's obvious where you need to go. Taiwan relatively recently decided on a single payer system after looking at the evidence.
How to get there is the real problem.
5
I think a single-payer "Medicare for All" could start out with a suitably structured "Medicare for Anyone Who Wants It", offered as an alternative for private insurance, either individually-purchased or employer-provided.
Craft a law that enables any individual, currently with or without health insurance, to put themselves on "MFAWWI" instead. If they have not got insurance currently, they will be taxed on their current income, offset by subsidies similar to those the ACA offers currently. The difference here is that would be nationwide, not up to each state to opt in or out. If an individual currently -has- private insurance, either self-purchased or employer-provided, they could opt instead to have the same premium amount go towards the MFAWWI plan instead. If an employer was currently paying a higher percentage for the employee's coverage, any leftover percentage would be given to the employee, taxed as ordinary income (this would phase out over 10-20 years). Increases in salary would apply to the MFAWWI and surplus amount at the same percentage as the base salary.
Given that Medicare is working at 3-5% overhead, instead of 12-20% for private insurers, it seems likely that equal or better coverage could be had for a lower percentage of an employees wages, leaving most private employer-insured people with a surplus of some amount. The employers are spending this amount already, so it is no change for them. My prediction is that this plan would take over, given time.
4
"The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform."
This is demonstrably false. The Democrats passed the ACA in 2010, and it has never been very popular due to its complexity and uneven benefits, and as a result the Republicans, campaigning against the ACA, swept the House and picked up 60 seats later that year. The Republicans then made further gains, while engaging in faux attempts to repeal the ACA, and won the Senate in 2014 and the presidency in 2016.
Now, the Republicans are still attacking the ACA. Many people hate it, because it can cost thousands of dollars a year on the exchanges. Warren's public option plan would also be unpopular and cause losses in the 2022 midterms, in part because the free benefits phase out at modest income levels, requiring a lot of people to pay for public coverage, and in part because many people would be stuck on inferior employer-provided insurance and would resent those at lower incomes getting a free buy-in. The Republicans would campaign on that resentment and probably take back the House in 2022, preventing any subsequent ability to pass Medicare for All. Once the Republicans controlled the House, they'd then demagogue against the public option and use it make more gains.
We need Medicare for All. It's simple. Everyone would be covered. and the benefits would be even. Bernie Sanders has the right idea.
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@Patrick
You haven't "demonstrated" the falsity of Krugman's statment in any way. Democrats took back the House in 2018 because voters wanted to save the ACA. Of course, Republicans under Barr are challenging the consitutionality of the Act but it's dubious they will prevail even under the Roberts court. Many "hate" the premiums they have to pay but this was true before the ACA, and would probably have gotten worse were it not for its passage. Many approve the ACA, particulalrly its provisions for covering prior conditions and children under the age of 26
7
@Alan J. Shaw how can you suggest that the Democrats benefited politically from the ACA because they retook the House in 2018 when, in fact, they lost the House in 2010 due mainly to Republican demagoguery over the ACA and they (a) failed to win back the House in 2012, (b) failed to win back the House in 2014, and (c) failed to win back the House in 2016?
To the contrary, the ACA was an unmitigated disaster politically for the Democrats. In addition to losing the House, Senate, and presidency in large part due to the ACA, the Democrats lost around one thousand state legislative seats lost during the Obama years, and only won back starting in 2018 because Trump is so unpopular.
Plus, the ACA is costly or unaffordable for a lot of people, as would Warren's public option buy-in be, probably. The public option buy-would likely also cause the Dems massive losses politically.
What IS popular? Social Security and, to a lesser extent, Medicare. Why? Because they're not means tested, or in Medicare's case only partially means-tested. But Social Security especially is a classic example of a non-means-tested program, which is why it's so popular.
Medicare for All, as proposed by Bernie Sanders, is a non-means-tested program, which is very simple to understand and has its benefits distributed evenly across the population. It would be popular and would cause electoral gains for the Democrats rather than losses. It's what we need.
3
@Patrick
You've answered your own question: Republican demagoguery but it only worked for a limited time, as demonstrated by the 2018 election, in which, as Krugman points out, concern for loss of a succesful program is a powerful motivator. Is the ACA "costly and unaffordable" or the premiums of insurance companies, pharmaceutical prices, and the fees doctors and hospitals charge? How and why will these entities be persuaded to accept what the government pays without supplemental insurance? Will Medicare for All cover undocumented immigrants? Social Security may not be means tested, but deductions are made for Medicare coverage, often a burden for those with low monthly benefits, and disbursements are taxable to those whose income is above a certain level. I look forward to a time when the entire populace receives free medical coverage on the level that Trump and Dick Cheney have, but I think it will it is more likely to happen and become popular through progressive legislation and reform.
2
The ACA was passed almost 10 years ago. But here we are, still talking about healthcare, because the costs are still too high.
Medicare For All would decrease the overall cost of U.S. healthcare. I'm in favor of that plan, or any other plan that would successfully decrease healthcare costs. I'd like to spend the next 10 years talking about something (anything) else.
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Thank you for pointing out the obvious differences between the State races. Please, let’s not let the perfect be the enemy of the good enough for NOW. Once people even in Red States understand what a difference reliable, effective Healthcare makes in their Family, they will VOTE Blue. Nothing like experience to overcome propaganda.
Seriously.
6
Reform instead of revolution regarding Health Care Insurance seems much more palatable politically. Remember the Affordable Care Act, supposed to contain a public option as well? Apparently, that was too much for some politicians, afraid it might backfire...and compromise their own 'career' in public service. As they say, 'the best is the enemy of the good'.
7
@manfred marcus
My guess is that the public option was not part of Medicare because of the insurance industry lobbying against it.
They are terrified that once people see a government option working, a lot of people will be leaving private insurance.
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@manfred marcus
If I recall correctly, the "public option" option was dropped in order to recruit some bi-partisan support. Or was it to keep the Blue Dogs happy? Anyway, the ACA got NO RepubliCon support at all.
1
There is so much misrepresentation of Medicare for All from both the left and right, it’s frustrating for me to even read articles on the proposals. The most egregious misrepresentation comes from the US healthcare industry, and has for decades.
I’m currently an expat working in a country with socialized medicine. Previously my work was in the US, work that included a platinum health benefit. I once had an infection that required outpatient surgery. I had to wait almost two weeks for the surgery appointment and by the time of the treatment day, it had already erupted. So, even though the surgery didn’t actually take place, the final course of treatment did. The copay for the entire ordeal came to almost $1000, the platinum 10% of total cost.
Recently, as an expat I had a similar infection requiring similar treatment. I went to the local clinic which, yes, was crowded. But, I was treated and had outpatient surgery all in the same morning. I was examined within the first 15 minutes after my arrival. Two weeks later I had a second outpatient surgery. The entire bill came to less than $500. It was 2/3 the platinum copay in facilities and with medical staff very comparable to those in the US.
No, US healthcare system will never be cheap for many factors, but eliminating the triple profit of insurers’ cut, for profit clinical cut, and private for profit group treatment cuts within the clinical system will get early reduce the individual’s cost of healthcare.
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Essentially we are talking about good living, large system design. You have a top a top down concept, and but implement it from the bottom up, testing along the way. While doing so the system can be alive and useful. The intermediate results may give valuable feedback for improving the top down design.
A lot less waste and less risk of complete failure.
5
Project planners have a saying: “don’t try to boil the ocean.” In other words, incremental change lets one patch the holes as one goes, and sells decision- makers on taking the next step.
I’d suggest the same plan for health care reform. Let’s take it one step at a time. Remember all the problems with the web site for the health exchanges? Imagine that times 1000 if we jumped straight into Medicare for all.
6
@John M
Thank you for the reminder about the many health exchange failures. Oregon had one of the worst roll-outs of all. I believe the state is still in a legal battle over the software provider. What a waste.
I like Warren's plan, except expecting a majority of people to feel the benefits of incremental improvement before the end of her first term is unrealistic. Many basically healthy people will not experience expensive illnesses in a period of four years. For them the improvements will still look theoretical.
4
Exactly, "...successful health reform, even if incomplete, creates the preconditions for further reform." Figuratively speaking, we can not go from A to B by going to Z first. I was one of those old nurses along with my younger peers who actively worked for what was to become the ACA. I was thrilled and proud to think that the Obama administration was able to accomplish something that seemed but a dream about a decade or so before. Senator Warren gets it, and she is listening to the people. Now that the majority of Americans are experiencing what can be done for them and their health, they justifiably do not want to risk too much of a change too soon. To put it bluntly, it's scary. And here's the deal for me with the Senator. She has what it takes to be a national and global leader. Not to mention I would love to see her be our first woman president. And as we saw in both Kentucky and Louisiana, health care and education were uppermost in the voters' minds. So keep on listening, Elizabeth. You may be able to do it.
39
Healthcare is far from perfect. But removing any and all profit motive removes the breakthroughs and sacrifices the quality of the product. People have to choose - cutting edge medical breakthroughs which cost money and leave people uninsured? Or single payer where the incentive toward quality and breakthrough treatment is largely removed.
I went to Northwestern University Medical School. There was a reason 1000s of Canadians came to the cardiovascular unit every year. Yes they have nationalized healthcare but when it counts, where do they want to have their surgery?
5
@Jason - what medical breakthroughs are you expecting the bureaucrats at health insurance companies to come up with exactly?
The United States has a declining life expectancy, rising infant mortality and over 500,000 medical bankruptcies a year. That's where it counts.
30
@Jason How did all those Canadians pay US prices for that heart surgery without insurance? They must have been on the rich side. Can most Americans pay for heart surgery without insurance? No. But I take issue with the suggestion that a single-payer system is always deficient "when it counts." It "counts" to get basic preventive healthcare from a primary doctor and early diagnosis of lethal diseases when they are most treatable (and cheaper to treat).
21
@abigail49 I’m not sure if the responses to my post have adequate knowledge of how the current system works.
Private insurance companies, as flawed as they are, reimburse at much higher rates than Medicare.
Arguing that the insurance companies don’t produce breakthroughs is a clever quip - except that they do by way of the budget flexibility they afford hospitals.
Folks I’m on the side of patients and outcomes. I have no affiliation with insurances companies. But to suggest that outcomes and new developments will equate to what they are now in a 100% government run system is naive at best.
The insurance companies are a profit driven oligopoly. The government is a clumsy and inefficient monopoly. Pick your poison.
2
I got to retire early because my company, as an incentive, offered to pay the premiums on my healthcare until I reached the magic age of sixty five and the ultimate goal of medicare. I was not the only one to take advantage of the offer. In the first three years of a Warren presidency she should allow those who have reached the age of 63 to utilize medicare if it suits them. Then, after that gold rush is over, offer it to those 62 and older in her second year and 61 in her third. By her forth year in office the population will be clamoring for Medicare For All and her reelection.
78
@Rick Gage ,
That's actually a pretty good way to do it.
2
@Rick Gage
The original 4-5yr roll in of M4A transitioned thusly; Year one, improves Medicare by adding dental, vision and hearing benefits and lowering out of pocket costs for parts A&B, lowering the eligibility age to 55 and allowing anyone to buy into the M4A program. Those 19 'n under are automatically enrolled. Year two, eligibility lowered to 45; year three, 35.
Warrens drug cap is $6,000 per. yr. out of pocket. Sanders is $200.
https://pnhp.org/what-is-single-payer/senate-bill/
https://www.sanders.senate.gov/download/medicare-for-all-act-of-2019
https://www.sanders.senate.gov/download/options-to-finance-medicare-for-all?inline=file
5
There are more than one way to get to a healthcare system that serves all the people without bankrupting them.
Canada does it with single payer.
The UK does it with a government-run system.
Germany does it with primarily private insurance and private healthcare.
Yet all these systems have a role for government to regulate private interests and serve the public welfare.
This is missing in the US. Where our government regulates it tends to serve the interest of wealth: insurance companies, pharmaceutical companies, big hospital networks. No one is looking out for the public good.
This is the change we need.
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@Victor
After all these years, I wouldn't trust private insurance in our country.
Unfortunately, I understand why Sanders and Warren are pushing Medicare for All.
14
@Victor You went to the moon...you can surely improve the health care system; it is just a question of will!
6
Thanks Paul for the article. We live in a country that use to try things and see the end result for the betterment of all.
Now we live in a country that is run by no account politicians that just want to be re-elected.
We once had a country for all and now it's for only the few.
Common sense will prevail with decency in all aspects of our society.
Let's elect leaders that follow this path.
8
Incrementalism is the only politically viable alternative. Had Max Baucus allowed a public option to be discussed in the Finance committee we would be 9 years into implementation by now.
That said, our medical care system is so flawed and expensive now, there is no way to reform it before it implodes. Recent small example, coronary artery disease causing chronic angina treated medically and less expensively than surgical treatment is just as effective.
The howls from the interventionalists is building. Too many dollars in surgery. This is only one small example.
6
@kirk
Yes, Max Baucus, that's right! How quickly we forget. And how do we know he wouldn't have voted for the bill anyway? Obama was far too quick to compromise, IMHO.
7
Nobody is going to establish a working single payer health care system in three years. That's simply magical thinking. It's not just a political problem but it's a problem of designing the new system and planning for a transition with the consensus support of the American people, not just a simply majority. If it happens it will likely take up at least twelve years of sustained efforts. Meanwhile, the challenge of reducing the costs by half while retaining the full service now provided will become an existential issue.
Warren is right to break this into stages and Bernie is still too wrapped up in the perfect imaginary possibilities to think soberly about the whole package and how it will actually work.
Getting a consensus is likely to be a big challenge. The propaganda against the ACA was effective and it took years after the law was implemented before the support for the ACA became high. The Medicare for All plan is very likely to be misrepresented even more successfully than the ACA.
13
@Casual Observer the anti ACA propaganda worked until the reality of "O my God, the affordable health plan I just got from Obamacare is gonna go away unless I raise cain with my legislators!" Let's face it, you don't know what you've got till it's gone. Trump knew that and his lying campaign promise, of "an even better health plan" with me in charge helped in putting him in the WH and putting this country into the mess that currently exists. The benefits of affordable healthcare for all as well as mr.president's above despicable health care lies.
Any substantial, new and permanent (not time limited) legislation, such as Medicare for all, with or without private insurance or free college tuition, needs a supermajority approval of 60 votes in the Senate. A temporary bill, such as the 2017 tax law, can be approved through reconciliation that needs a mere majority (50 if the VP is a Democrat). Passage under the latter situation would require that the Democrats pick up 3 additional Senate seats, certainly possible as there are 19 Republican seats up for election, versus 14 for Democrats, assuming the Democrats don't loose any seats. Even a net gain of at least 3 seats requires the Democratic candidate to have substantial coat tails. But I doubt that any present aspirant to the presidency can pull in a super majority, especially if an overly ambitious health plan like Sanders' or Warren's is the principal platform plan, and even less so if other controversial policies such as free college and college debt forgiveness are included. The majority of Democrats are moderates open to evolutionary progressive ideas that do not shake up the system. Those Democrats are the ones who were elected in Kentucky, Louisiana and Virginia. They were not firebrands.
1
@Rudy Ludeke
Obamacare was passed in the Senate without a supermajority.
Pelosi ordered Democrats in the House to vote for the bill so that they could see what was in it. The ink was not even dry, so there was not time for anyone voting for it to read it before the vote was taken. And the House could not change a comma in the text or it would not have passed reconciliation.
Pelosi's order to the moderates in the House cost her the majority. It is an absurdity to even suggest that her order was anything other than a demand Democrats vote for the bill without reading it.
1
@ebmem
ACA was passed in the Senate by a 60 to 39 vote, after a cloture vote than ended the Republican filibuster.
1
@ebmem --Krugman addresses this misinterpretation of what Pelosi actually said about the bill in his opinion piece. You might want to read the piece before commenting on it.
2
Every other rich industrialized country has decided that everyone should have access to health care and has managed to develop systems that deliver a basic standard of care to everyone at uniform, transparent prices.
We, on the other hand, are as a country still fine with expensive fragmentation that leaves many out completely and many others bankrupt. Some exceptionalism!
24
@IndigoBleak - American Exceptionalism = Everyone can do it EXCEPT Americans.
@IndigoBleak
Democrats constructed Obamacare without input from Republicans. They passed it without a single Republican vote and used a parliamentary trick because they didn't have 60 votes for cloture.
In order to get support from big medicine cronies, they created a monster that increased the profits for hospitals, drug manufacturers and distributors and insurance companies. But it makes sense that Obama and Democrats would devise a law that was exceptionally defective because Obama thinks that Russia and China are exceptional but for the evilness of America. His dream from his father was to enrich the autocratic leaders of the world and to denigrate Americans.
The American public is not going to elect a Democrat to the presidency as long as they are promising another round of medical malpractice.
If Obamacare was not going to add one thin dime to the national debt and is at $1.5 trillion after eight years, how much profit is going to be added to big medicine with a plan that is estimated to add trillions to the national debt?
Fool Democrat voters once, shame on politicians. Not even Gruberized voters are going to go for a second round of profiteering.
Slow progress, testing what works, refining, improving. That's a genuinely conservative approach to progress.
2
@jwdooley
Measure twice, cut once. Its a highly effective approach to progress.
1
How can anyone trust Warren if she criticized Pete and others for the policy that she now embraces?
Who knows how many other deep seated other leftie policies she will abandon when the going gets tough?
At least Bernie sticks to his principles.
Not so Warren.
She is more interested in selfies than principles.
5
@Simon Sez
Her plan is different from Pete's. Pete talks about a public option you can purchase (it's not free), but he has not proposed anything more than that. Warren is has set a goal of getting to free coverage for all Americans, with interim steps that get us there in a relatively short time.
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@Simon Sez This is going to cost her. It makes me sad, but I have always preferred Bernie, he is a rock and has always fought for us and for justice.
4
@617*
Please stop saying it’s free. It’s not free. It’s tax payer funded.
Nothing is free.
1
One detail that I think escapes many Americans:
The Warren and Sanders single payer plans provide full coverage for all necessary medical services, with no premiums and no deductibles, copayments, coinsurance, or other out-of-pocket costs. Under their plans every American would have comprehensive coverage throughout his or her life without any costs. Of course, the plans would be funded by taxes, so people with enough income to pay taxes would fund the program. But there are no payments required to participate in the health plan.
The other "public options" all require premiums and most have cost-sharing provisions at the time care is received. This means some Americans will still struggle to afford coverage. Warren and Sanders get us true universal coverage affordable to all. All the other public options merely offer one more option that, like the private plans already available, has a cost and therefore won't be affordable for everyone.
26
And, you get a pony. And chocolates.
1
@Robert
Well, I live in Canada, so I already get the "pony" of free healthcare. Only in the self-proclaimed "greatest country in the world" is such a program apparently beyond the nation's capability.
So Warren is praised for endorsing something more similar to what Biden has been pushing all along? I don't disagree with this incremental approach but at least Biden cannot be accused of hypocrisy on health care. The US will eventually have to enact a single payer plan in the future but to secure the buy in from enough voters and health care providers is going to take a long time. It's easy to dismiss health insurers but the industry does employ a fair number of American workers, both directly and indirectly. Furthermore, will doctors and other health care providers universally embrace much lower Medicare negotiated rates for their services which could translate into large income losses for them? There are lots of unknowns with single payer. And yes, no one loves their insurer but many people are terrified of losing their familiar insurance.
7
@Jeff No. Even Warren's incremental first step goes further than Biden's proposal, and there is no step 2 to Biden's plan. Biden proposes to tinker around the edges of the ACA; Warren proposes getting to single payer. That's like saying that the moon landing was similar to what the Wright Brothers did.
27
She's a smart lady, don't underestimate her. The others are recommending we open negotiations asking for half of what we want which is a sure fire way to end up with nothing. She knows it's not going to happen on day 1 but she has a clear vision of the finish line and has the courage to put it in writing.
I am weary of all the worry about alienating swing voters. These unicorns are clueless and catering to them will guarantee we end up with another milquetoast candidate. We need someone who will inspire those who stayed home last time to get out there!
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@Johnny
By what authority does the government have the ability to tell people what to do? By the authority which all citizens give, not just the winners of one majority vote. This is an issue which requires consensus or it will not be sustainable.
5
Voters should vote for president based on an overall assessment of their performance as Commander and Chief and the chief executive officer of the United States, stemming from current performance and experience. Whether they believe in Medicare for All or not is only a single policy belief on a single policy only, and not an overall assessment of how they would do as president. There is a lot more involved in the presidency than yes or no on Medicare for All, an issue on which they can change overnight.
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@David
Yes, performance as Commander in Chief is supremely important. So is performance as Chief Executive, both to "see that the laws are faithfully executed" and to give direction to the executive branch. Note how instead, the Republicans have chosen Trump, who is inexorable at both. They got tax cuts for the rich and enough right wing federal judges to eventually outlaw abortion, even though Trump could never get a majority of the American people to vote for him. They also hoped to deprive tens of millions of Americans of health care, but narrowly failed.
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@Marvant Duhon -- I think you mean "execrable" rather than "inexorable," but otherwise I agree with everything you've siad.
Unfortunately even actual Medicare is getting undermined by Medicare disAdvantage plans, actually private HMOs. The problem with HMOs is that they get a set payment whether you get care or not, so every dollar of care they can deny (or simply not tell you you need) is a dollar of pure profit. Who would have guessed?
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@Dan Woodard MD - Prior to the ACA, Medicare Advantage companies were paid 15% more than regular Medicare paid, with the money taken out of OUR Medicare dollars. The ACA did away with that, but we learned from our insurance representative that the insurance salesmen are paid $700 for each new Medicare Advantage enrollee. Does that come out of our Medicare dollars as well?
7
@Dan Woodard MD Ah have you read Bernie's plan? It is far more comprehensive than the Medicare we have now, no Medicare advantage or other supplemental plans needed. No profit for the profit run leeches. Nope, And vision and dental included. No co payments, no deductibles nada out of pocket.
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Why can't the government provide protection for those with medical bills that cause bankruptcy without having to disrupt the normal everyday medical system? This would address Sen. Warren's main concern and would seem fairly uncontroversial.
How much would such a system cost?
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@Peter
Sort of insurance-after-the-fact, with no premiums.
So medical corporations (aka the medical mafia) would provide care, knowing they would not be paid, or maybe be paid reduced rates by the government, maybe?
How is that gonna work?
The everyday medical system is broken, with people getting care based not on what they need for healing, but on how much the medical mafia can run up the bill without getting caught.
The system can only be changed radically. To put it in economic-speak, there are no incentives to provide value in medical care, only for those at the top to milk the system. We pay twice as much for medical care as other countries, with worse outcomes. The everyday medical system is working for some (at a very inflated cost) and failing overall and must be restructured.
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@Tom So what is wrong with putting a limit on what can be charged to individuals after medical costs exceed a certain amount, with the government charging Medicare rates after the costs hit that limit? That would put pressure on the largest cost issue.
And this wouldn't affect the majority of health care that people receive.
Your solution seems to be pretty blunt about rationing care. It's why it can't pass and will bring Warren/Sanders down.
1
"Sanders supporters are, predictably, crying betrayal."
Well, given Bernie's larger-than-life achievements, this reaction is to be expected.
After all, he managed to get 3 post offices named in a mere 30 years in the Senate. Surely he'd get Medicare For All done on his first day in office.
Not so?
17
@spindizzy This is a serious misrepresentation of Sanders' effectiveness. As a "party" of 1, he's been called the amendment king for making changes that matter, including in Obamacare. But the power isn't with Bernie. It's with us and whether we want a better health care system that doesn't fall prey to insurance company fear tactics.
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@spindizzy
He’s given us hope. He totally changed the conversation around health care and other politicians are following him. I’m not sure what your snark is about, but because of his commitment people are starting to see that it might be possible for them to finally get care. I want our citizens to live. Don’t you?
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@allseriousnessaside
Actually, @spindizzy presented an exact and precise representation of Sanders' effectiveness. Comparing Sanders to Socialists, Progressives, and others on the left about a century ago, one difference shines out. The major figures of old worked hard to help elect others to lesser offices, from school board and city council on up. Bernie Sanders is renowned for helping almost nobody else get elected during all his decades in Congress.
Heck, he's hardly ever endorsed anyone, much less recruited people to run.
5
The difference between Warren's plan and the other incremental approaches is that Warren's plan moves quickly toward the ultimate goal—a plan that covers all Americans for all essential medical services with no premiums and no out-of-pocket costs and that is paid for by taxes which can be targeted toward those individuals and corporations with the money to pay them. The other public option proposals take a small step in the right direction, but fail to define any future steps toward any clear goal. Sanders, on the other hand, has the right goal, but it's not clear he has the right steps to get there.
Once again, Warren proves herself the best candidate: she has the right goal and the right steps to get there. No one else in the field has anything close to that.
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@617to416
Perhaps she has the goal and steps. The problem is her. She simply has not the political skills to get anything accomplished. Her abrasive non negotiable manner will lead to four years of nada. Worse than Obama had with the GOP.
1
Try to understand the economics: elaborating intermediate steps is not urgent. Simply enact a Medicare-equivalent public option, and private insurance will wither on the vine. Market forces would bring M4A with minimal legislation.
2
@Guillermo
That all depends on the pricing of the public option. If you price it cheap enough, it may destroy the private insurance market. But then you have to pay for it, which means you need a Warren-like plan for raising taxes to fund free or near-free health coverage. If you don't raise taxes and therefore have to price it to cover its costs, then it isn't going to be much cheaper than private insurance so the current system won't disappear.
The public option is a platitude that sounds nice, but until you present the cost and funding details it's meaningless.
2
Thanks for this, Mr. Krugman. Elisabeth Warren had lost me with her earlier stance of wanting to force universal coverage on people who simply do not want it. It is not the American way, and as I see it, there is no reason why people who want to keep their health care should't be able to do so.
I was giving my vote to Mayor Pete because of her earlier stance. Now I have to think about it some more and watch them both closely.
17
I'd like this to be true and hope it is. But by the same logic, one might have seen Medicare (passed on 1965) as the first step toward universal care... and it's been over a half century and we're still waiting!
Let's hope you're right, PK!
5
@FF By making Medicare an entitlement of passage the chance of having medicare for all was diminished.
Seniors or anyone else will not vote to make themselves less special. In terms of investing, medicare increases longevity and productivity. Medicare for seniors was windfall for insurance companies who know half of lifetime medical costs occur in the last two years of life and insuring seniors will never be profitable.
4
Politics is the art of the possible. Warren is wising up to that, or maybe trying to wise us up. What would be possible might include funding ACA subsidies for middle-class people and extending ACA to include low-income beneficiaries in states that have failed to expand Medicaid.
The money is there already to do that.
5
@jon_norstog What is possible is what is made possible. Going big moves the Overton window and sets the ground for a near-term compromise in the right direction. Starting small barely changes the status quo. https://en.wikipedia.org/wiki/Overton_window
Americans are ready for the public option that didn't make the cut in 2010. This would allow the market (i.e. health care consumers) to decide whether they prefer government-funded or private insurance. I'll bet there will be a significant initial sign-up for the public option, but many will retain their private. Then we'll see how things work out.
16
Without public acclamation, nothing the actual progressives are running on will ever be enacted. Even getting a majority of Democrats will be insuperably difficult.
It can be assumed both Warren and Sanders would undertake whatever reform can be achieved by decree. And both will have decent judicial, cabinet and agency appointments.
The only real difference between them may be one only of salesmanship, since all programs, far reaching and more modest, will fail if they're not sold in a way that's new to the Democratic party.
Who can get people in the street? Who will even ask?
2
The issue is trust.
The current system is a mess, expensive for everyone, and a disaster for some. But it does mostly work for most people most of the time and changing the status quo is scary, even compared to the promise of a better solution. Better the devil you know.
Medicare for All requires trust in a government that has not earned it.
Republicans have shown they cannot be trusted to keep from dismantling safely net programs. But Democrats have also added to the lack of trust in new big programs by their rhetoric (alas just by being honest):
Progressives argue effectively that industry consolidation is harmful to consumers. Warren has called for the break up of Big Tech and Big Ag. Banking, Airlines, Telcom are also on her radar.
Progressives argue effectively that politics has been corrupted to it's core. Sanders has been especially outspoken on this topic for years.
Then Progressives say: We must consolidate the entire health care industry under single payer to be run by our utterly corrupt government. All at once. And before we implement that miracle of taking big money out of politics.
Just trust us?
I fear progressives underestimate the difficulty in getting that trust from a large enough majority of Americans to make a fast jump to M4A politically viable.
I don't think you can build that trust just from speeches -- you have to earn it with successful incremental changes -- even when changing a poor system that is not well trusted.
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@LT I certainly trust that in the current system, health insurance companies serve only one purpose: to make profits for themselves. There is nothing wrong with that if they are adding value to the system. But health insurance companies basically add no value to the system. On the contrary, they have an incentive to deny as many claims as they possibly can. And with most of the regulation being self-regulation, they get away with it most of the time.
36
@LT - Medicare insures all the oldest and sickest Americans for LESS than insurance companies charge to insure their cherry-picked younger and healthier population. I'd trust Medicare in a heartbeat over any private insurance company. I've been on Medicare for almost 9 years now, and my husband was on it for 18 years. We had a combined almost 40 years of experience with it, and it was much superior to our "cadillac" employer insurance.
56
Medicare is the most trusted healthcare insurer in the country. Single payer healthcare doesn’t consolidate healthcare under one government run organization. it just gets rid of the high overhead of profits for insurers to administer all sorts of different plans.
Those who have Medicare are largely happy with it. Your arguments can be dismantled and proven to be wrong one by one.
Everyone needs access to medical care. It’s not a matter of “if” it’s merely a matter of “when” and “for what.”
23
Incremental change is not a cop-out, in this case.
None of the countries with universal health care still have exactly the same system they began with. All solved problems with their original designs until they worked better. They continue to evolve.
The American universal health care system will evolve, too, unless it is strangled in its infancy.
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@Merilee Karr The majority of countries that now have universal health care may not have the same systems with which they started, but they did start with one of four basic models, each of which was designed to include everyone and with regulations that resulted in nationwide uniform and transparent pricing (See T.R. Reid, "The Healing of America"). The ACA was not designed to do either. Perhaps if it had been it would have been more widely popular and harder for opponents to attack.
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@IndigoBleak A big IF there. More likely, if it had included full inclusiveness and transparent pricing, it would have died in Congress. Incremental change for the better may not be sexy, but it certainly is more likely to be durable than a revolutionary fantasy such as Sanders'...as well as a firm basis for moving in the direction of an ideal.
14
@PMJ Universal access to health care at bottom is a moral issue. Every other rich, industrialized country believes everyone deserves health care. Obviously, a lot of us don't.
40
Yes, Dr. K. is correct saying "Among other things, the election results vindicate polls indicating that Trump is historically unpopular", continuing a trend the right wing echo chamber misses/ignores - that the 2018 midterms were the latest election (not 2016's election) and that voters around the country in 2018 resoundingly put Dems in charge of the House to rein in Jabberwock 45*.
Agreeing about the expansion of Medicaid affecting Ky. and La. gubernatorial elections, this is a point for Dems to be pounding more often in the 14 states which did not expand Medicaid, and which are now seeing many many rural hospitals closing - in GOP'er environs.
Pelosi and the DNC need to be driving home the point that GOP'er policies not expanding Medicaid are directly responsible for such closures, and reminding - 5 years into Obamacare - of the huge medical industry investments not made in such states; in Texas alone, that figure has been widely publicized as $100 Billion$ over a decade.
Voters in the red states who are seeing rural hospital closures, and local officials dealing with hospital budgets, understand these real costs of not expanding Medicaid.
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@R. Law
Gallup just put out some poignant figures in a report. https://tinyurl.com/urynh9b
"STORY HIGHLIGHTS
34 million adults know someone who died after not getting treatment
58 million adults report inability to pay for needed drugs in past year
Little progress seen by Trump administration in limiting rising drug costs
Editor's Note: The research detailed below was conducted in partnership with West Health, a family of nonprofit and nonpartisan organizations focused on lowering healthcare costs for seniors.
WASHINGTON, D.C. -- More than 13% of American adults -- or about 34 million people -- report knowing of at least one friend or family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it, based on a new study by Gallup and West Health. Nonwhites, those in lower-income households, those younger than 45, and political independents and Democrats are all more likely to know someone who has died under these circumstances."
“The idea behind triangulation is to work hard to solve the problems that motivate the other party’s voters, so as to defang them politically… The essence of triangulation is to use your party’s solutions to solve the other side’s problems. Use your tools to fix their car.” This is what we got for not getting universal healthcare in 2010. https://tinyurl.com/ql4eu8f
5
@R. Law
The issue of sustaining rural health services in the U.S. is an interesting one because the European countries with national health insurance programs don't have large rural areas to deal with.
Although most of Canada's population is concentrated in a strip within 75 miles of the U.S. border, it does have enormous sparsely settled expanses.
It would be helpful to know how Canada ensures that its rural citizens get medical treatment, whether Canada's rural areas are comparable to ours and whether rural Americans would be satisfied with the arrangements that Canada makes for rural health care.
3
@PWR - You list reasons it would be good for the DNC to pressure states like Texas to expand Medicaid as a first step, finding out what is required in large rural swaths.
Of course, since Texas is only exceeded in population by Cali, there are actually other, more rural states where Medicaid was already expanded, which might offer better learning examples - perhaps Montana pr Wyoming?
The DNC has a natural policy wedge which they should be more cleverly exploiting in turning red states purple.
3
Medium size reform only does two things: delay the inevitable and, in the process, deny worthy humans their right to a humane life.
We all contribute to society. Over the last two years, some among us were given a free pass while the rest of us were saddled with their obligations.
Time for the arc of justice to swing back around.
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@Rima Regas - Politics is the art of the possible. At present the voters are not yet with single payer. But they do support "Medicare for All Who Want It." So go for that goal and over time the number of people with private insurance will dwindle. That is why the insurance industry made sure that Joe Lieberman killed the public option in the ACA.
25
@John Graybeard
A tiered system, which is what we have in the United States, is what makes the delivery of healthcare so terrible. We have the capability of treating everyone who needs treatment but access to healthcare is prohibitive to those who are outside the upper echelons of what’s left of the middle class. By instituting Medicare for those who want it, we will doom the expanded version of Medicare by virtue of introducing inequality into it.
When everyone gets everything covered, at the same relative cost using all available means, rather than separate medical networks, then everything becomes even for everyone.
There is no justification for continuing to award billions in profit to private insurance companies. That money is the missing funding for those who go without treatment because copays and deductibles are too expensive, or for those who die way too soon of perfectly curable conditions.
We can do this, just like we could do the ACA, but fairer.
8
No reform does anything unless it is enacted, not all reforms are equally enactable, and some reform is better than no reform. If medium reform is the best we can do this time around then let’s do it. I don’t want no reform.
11