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'Everybody In, Nobody Out': What's Known About the Medicare for All Act of 2019 (commondreams.org)
43 points by howard941 14 days ago | hide | past | web | favorite | 75 comments



I think that being able to leave a job and still have the same health care would be transformative for entrepreneurialism in the United States.

I’ve known lots of folks over the years who’ve felt tied down to a job because they were the only member of their family to have health insurance, and they couldn’t afford to risk their spouse or children getting sick.


I think that's a big reason so many non-insurance companies are fighting against the idea of universal healthcare for all citizens, they like having this tremendous power/leverage over their employees.


That's interesting. I've wondered for a long time why non-healthcare industries don't lobby hard for universal healthcare. It's a huge cost and administrative nightmare.


This. When I lost my job in 2013, I considered making an attempt at a freelance/contract career. That stopped when I got a rejection letter (not an increase in price, a full-stop rejection) from my preferred open market insurance provider. (And it was for being too skinny.)


My insurance isn't great, but I hit my copay (and Out-of-pocket-max) for the year in January, so I'm locked in for the year.<br><br>Come to think about it, maybe this is part of the plan for High Deductible plans.


Ugh this is so true. The high-deductible plans are designed to both reduce costs to employers and also keep employees locked in due to high out of pocket max.

At this point we are just paying to avoid the Obamacare tax penalty.



Yes I know not any more after tax year 2018.


Agreed. There's actually a term for it: Job lock. https://en.wikipedia.org/wiki/Job_lock


You don't think you still would be paying for it, just because you loose the choice of whom your paying?


I have no idea what you're trying to say.


Want to bet the actual legislation is just minor tweaks to ObamaCare re-branded as "Medicare for all"? Why do I suspect the article is overly optimistic and that the author is just reading into vague and noncommittal comments made in meetings that they think will make it into the bill?


The ACA is loosely based on the ultra-conservative Heritage Foundation’s 1990s-era alternative to ‘Hillarycare.’

Medicare for All, definitionally, offers single-payer access. The Heritage Foundation was trying to prevent exactly that.

Also, I can tell you’ve never spoken to Congresswoman Jayapal, because she doesn’t make vague or noncommittal statements (source: I’m a constituent and have been to several of her constituent coffee events.)


Sidebar: in the two hours since I posted my comment above, Jayapal has announced her first town hall event of 2019. Seattleites should come and ask her questions about Medicare for All. https://twitter.com/RepJayapal/status/1093942183495905280


"Medicare for All, definitionally, offers single-payer access..." Yes that is what the definition of Medicare for all should be but we are already seeing presidential candidates trying to redefine "Medicare for All" to the point that it doesn't mean much at all. I hope you right on Jayapal but till we see the bill's text we won't know.


we are already seeing presidential candidates trying to redefine "Medicare for All" to the point that it doesn't mean much at all.

What are you referring to?



That is disappointing. Thanks for the link.


Maybe the government should treat healthcare like it does student loans. A healthy, educated person is more likely to make more money, and pay more in taxes. So, its more of an investment then a handout. Money flow wise, it makes more sense for government to pay the healthcare for a working adult then a retired one. And they already pay for > 65 year olds and offer student loans to any student.


The problem with over promising with healthcare is that you can't walk it back and healthcare becomes the most expensive or second most expensive thing on the government budget.

The other problem with government healthcare is that you're basically giving the government some control over your body. It will be the government's business whether you're out of shape or overweight or indulge in too much sugar etc, because the government is paying the medical bills.


> healthcare becomes the most expensive or second most expensive thing on the government budget.

Has that happened in other advanced economies? Genuinely curious - I don't know what share of the UK national budget the NHS consumes, for instance.

> It will be the government's business whether you're out of shape or overweight or indulge in too much sugar etc, because the government is paying the medical bills.

First off, this happens to a small extent already with private insurance companies. Companies do "wellness fairs" for employees, insurance companies give people discounts for going to the gym etc. It could increase in future right?

Second, I think most people want to be healthy, regardless of who's paying the bills, because your quality of life is so much better. I could see many people not changing their oil on time and driving terribly if they were guaranteed free car repairs forever. But healthcare isn't like that.


>Has that happened in other advanced economies? Genuinely curious - I don't know what share of the UK national budget the NHS consumes, for instance.

Yes, this is the case in the UK.[1] Public sector spending for 2019 is around £842 billion for the UK. £256 billion is spent on "social protection" and €166 billion on public healthcare. That's 18-19% of the total budget being spent on healthcare. Keep in mind though that healthcare in the US would be much more expensive. US healthcare workers earn more compared to GDP per capita than UK healthcare workers.[2] I think it would be rather likely that healthcare such as this would rival social security in terms of cost if it applied to everyone.

[1] https://www.gov.uk/government/publications/budget-2018-docum... - under section 1.7

[2] https://economix.blogs.nytimes.com/2009/07/15/how-much-do-do...

>First off, this happens to a small extent already with private insurance companies. Companies do "wellness fairs" for employees, insurance companies give people discounts for going to the gym etc. It could increase in future right?

I think it's likely that it will increase, but now the government has more of angle to argue why they should have the right to control your behavior.

>Second, I think most people want to be healthy, regardless of who's paying the bills, because your quality of life is so much better. I could see many people not changing their oil on time and driving terribly if they were guaranteed free car repairs forever. But healthcare isn't like that.

Most people don't want to be told that they're not allowed to eat X, because a bureaucrat living a thousand miles away says it's bad for you, especially when the evidence isn't stellar. It also allows for corporations to lobby harder on laws around people's habits.

If the government finds that using "a screen" for more than 8 hours per day is bad for you, you probably wouldn't like it if the government would now argue that they should be able to monitor your usage of screentime and potentially penalize you in some way, right?


> It will be the government's business whether you're out of shape or overweight or indulge in too much sugar etc, because the government is paying the medical bills.

This seems more like a pro than a con, considering currently through lobbyists the government is more likely to encourage to you indulge in too much sugar, etc.


But are you sure we're going to get things right this time as opposed to all the other times? I have my doubts about that, which means that we could have the law try to promote "healthy food" that actually isn't healthy. The same goes for all kinds of other activities. Would you be alright with the government restricting how many hours a day you can use a computer?

That’s my point. If it’s an investment it’s not a cost center, but a profit center.


We are now facing the consequences of many decades of inaction to deal with the looming healthcare catastrophe. Now that a majority see a serious need for action, we will get an avalanche of progress.

If the Clintons had been a little less ambitious back in the early 1990's and proposed lowering the age for Medicare coverage by 1 year each year, we could have learned gradually how good an idea this is. If that had worked well, everyone over 40 would now be in (way more than 50% of the health care money), and we could have some confidence that Medicare covering everyone would be a good idea.

The course of urgent progress is seldom smooth.


And then once you put it into place you realize that your system is not sustainable, just like every other country's healthcare system due to demographics. Now you have a big problem on your hands and the only real solution is to cut back on spending.


Only in America can we have a military bigger than the next 10 countries combined, but universal healthcare is untenable financially.

If your demographics suck, use technology to increase healthcare productivity. If your practitioners are too expensive, train more so their wages are in line with other developed countries.

These are not unsolvable problems, and I do not trust anyone who says they cannot be solved.


I agree, but I do not think that we can write an acceptable, realistic, and unambiguous definition of 'solved' before we start, because fighting with a bear always involves some learn-by-doing. It will take a long time for people to accept that a new healthcare system is anywhere close to good enough, and we cannot confidently anticipate now what will be politically acceptable as 'good enough' after people get accustomed to living and dying under the new system. This could certainly be a project that could organically generate some shared values as a by-product, if it is done with political wisdom and skill, but that is just another aspect of a very rich strengths/weakness/opportunities/threats environment that must be navigated.

That would make more sense if we had a more preventative healthcare system. We have a mostly reactive one unfortunately.


Medicare is NOT health insurance. It is a credit card that starts to fill-up after age 55. States, by law, are required to collect on the debt you and your family acrue for your medical care. The government, in collecting this debt, will place a lien on your estate. Beyond that, your children can be liable for what you owe.

If everyone in the US were to be shifted into this program it would likely be the largest private property grab by a government anywhere in the world in modern history.

Don’t take my word for it, start here and do your own research:

https://www.medicaid.gov/medicaid/eligibility/estate-recover...

Not saying a better aporoach to healhcare isn’t necessary in the US. It is. Just saying this is not a good idea.


Can someone explain why it's worth paying attention? With a Republican majority in the Senate and Trump in office, the chance anything like this will pass before the 2020 election is nil. And whatever might pass then will be different.

I'm reminded of how when Obama was in office, the House attempted to repeal Obamacare 61 times [1] and it seems it was entirely symbolic.

[1] https://en.m.wikipedia.org/wiki/Efforts_to_repeal_the_Patien...


Because every Democratic candidate for President is going to have to have a position on health reform, and Medicare for All is emerging as one of the most popular options among those that have declared so far. So the question of what exactly Medicare for All would mean in practice is of primary importance to the agenda the eventual Democratic nominee will bring to the table.


I still think some kind of Medicare-for-all legislation or "Trumpcare" is Donald Trump's ultimate goal for his presidency. "I am going to take care of everybody... Everybody’s going to be taken care of much better than they’re taken care of now."


Trump only does what benefits Trump. Trump will sign what bills benefit Trump to sign.

If congress can put a healthcare bill in front of Trump that can be branded as "medicare for all" for one audience and "we repealed Obamacare" for another audience (the possibility of the latter branding being a necessity in order to get any Republicans in congress to vote in favor of the bill) then Trump will almost certainly sign it. It doesn't actually have to provide "medicare for all" or "repeal Obamacare". It just has to look enough like it does to pass it off that way to the American public. He just wants to be able to say "look everyone, I repealed Obamacare" whether or not it's technically true.

The "which news is fake news" circus and people's increased skepticism of what they read and see on the news should make the latter part much easier because it gives Republicans more wiggle room to vote for something that looks a lot like Obamacare 2.0 or "medicare for all" and then turn around and act like they repealed Obamacare in front of their base in 2020.

I for one am hopeful. This seems like a potential win for everyone (well, scummy insurance companies notwithstanding).


[flagged]


So, if the government denies a treatment that could save my life due to some cost / benefit calculation, I can't get access to that treatment, even if I manged to raise funds for it on my own?

Come to think of it, if this passes, I'm going to lose access to a medication that I'm taking right now. Insurance denied coverage for it because they want me to try a half dozen others first, even though all of them have significantly worse side effects. I'm only able to get what I'm currently taking because the manufacturer covers the cost through their charitable foundation for anyone who can't get insurance / insurance approval.

If "medicare" for all banishes not only private coverage but all private care, and that extends to coverage for drugs, I'm f*cked. Death Panels indeed :(


Your government-enforced death will enable millions more to have basic coverage so don't feel bad.


Granted, it's a condition that practically guarantees that my lifespan will be shorter than if I didn't have it. On the other hand:

1) We already have medicaid programs for the poor 2) We already have medicare programs for those not in the workforce (age, disability, etc) 3) We already offer subsidies for those who cannot afford traditional plans but don't qualify for a medicaid or medicare program 4) Medicare still costs money. It's a public insurance plan, not "free for all". So no, it won't give millions basic coverage that they couldn't already get.

I'd prefer my death to be a bit more meaningful than fulfilling getting some politician political points, because that's pretty much all it would do under such a system. The above points don't add up to a perfect society; maybe we could work on improving those instead.

Edit: For those not in the know, elderly pay for medicare out of their Social Security income. Anyone who reads "Medicare for all" as "Free healthcare for all" is either misinterpreting what's being offered, or what's being offered is a lie.


There will still be private providers.

Edit: read my response below before downvoting. There will be non-participating private providers.


> The bill ... will not allow participating institutions and providers to offer private care for covered services


Right.

So there will be private providers that do not participate.

The same thing happens in the UK - you could visit a private hospital if you want to (and many people do) but if the institution is a public-funded one then they don’t get to offer different levels of care for different people.

You can absolutely have a private, non-participating hospital or practice under the proposed plan.


My situation is one of medication payment, not in-patient treatments You can bet that one of the worlds' largest drug manufacturers, and the pharmacies that provide their medications, aren't going to opt out of participating. If the bill truly makes participation all-or-nothing, I'm SOL. (US health insurance covers both treatment and medication; I'm assuming that the participation rule in this bill applies to both).


> but if the institution is a public-funded one then they don’t get to offer different levels of care for different people.

This is incorrect. Many NHS hospitals have private wings, and since Lansley there's no laws or regulations to stop hospital trusts providing basic service for all and better service for paying customers.


Not all institutions and providers would choose to participate.


Maybe, maybe not.

Yes is a real possibility. I was born in a country where government is largely trusted and live in another. It's a mixed story depending on branch, but by and large people trust the government no less than they trust the average bigco, and partly more.

But you're in the US, which seems different, so maybe not. And I've always wondered: Why is that? You Americans seem to distrust your government so much. Why do you vote as you vote and get a result you don't like?


If you look at the success rate for US public schools, you may want better odds under a healthcare system. The VA is a good example of government run healthcare that continues to fail its members to an astonishing degree.


A major part of the reason the VA fails is that it is legally bound to provide coverage for people all over the country, with a center within X miles of every person that needs it, while only getting funding to cover roughly one percent of the population.

Singler payer healthcare works a lot better if everyone is covered because then resources can be allocated more efficiently.


Serious question: Do you trust the government to "efficiently allocate resources"?


I think that single payer will more efficiently allocate resources than the current system. I think this based on the fact that the countries that have single payer healthcare manage to produce the same or better health outcomes for a fraction of the cost of the us.

Part if the issue is that the incentives in the US today encourage the poorest people to get health care at the most expensive places (emergency rooms), as well as the insane amount of wasted effort coordinating insurance providers, billing people, verifying copay amounts etc.


>I think that single payer will more efficiently allocate resources than the current system.

I do agree with this.


How do you know that this is not due to government interface, I read somewhere that the non-subsided plastic surgery industry saw less increase in prices for consumers. Bear in mind that waiting times in socialist countries are way longer and also if you don't agree with the treatment that has been decided for there is nowhere to go. If you are looking towards the Swedish model for an example keep in mind that the direction there has been increased privatization.


>Serious question: Do you trust the government to "efficiently allocate resources"?

Not really. But I trust them to fuck it up in a way that sucks less than the status quo and when they fuck it up we have more recourse than we do with the status quo.

It's the classic choice between the devil you know an the devil you don't except that most other countries have chosen a different devil than we have and are doing better for it so I think it's worth a shot.


Yes.

I trust the government more than I trust insurance companies.


Depends, are we electing Republicans?


The VA business is interesting, because the right clearly does support the spending of almost unlimited amounts of money on defence, where presumably this is "efficient", but not on healthcare for the troops. I'm surprised nobody's suggested that soldiers should have to buy their own battlefield health insurance and choose from a selection of medevac providers yet.


Shhh... Don't make suggestions.


For the most part, people trust their state and local governments, but distrust the federal government; state politicians are commonly re-elected until they choose to retire. I think it's because the country is so large and diverse that what's good for one state may not be good for another. We've got cities and states with a higher population and more economic power than some of the EU members, but a huge geographic divide in the middle of the country. Culturally, people on the west and east coasts seem to be different enough that they don't agree with the politicians that are elected, then you have smaller states that feel bullied by the bigger states like New York and California. Eventually it starts to feel like the only people you can trust to look out for your interests are state and local politicians.

I've seen a similar sentiment from citizens of smaller EU members who feel that Germany and France are willing to push for changes that benefit themselves and the EU as a whole, even if the changes are detrimental to the smaller states.


Depends on what you're trusting them to do.

Here's my personal ranking:

When it comes to "I trust the government not to send a bunch of thugs to kick down my door and shoot my dog for no good reason" I personally rank them local > state > federal

For "I trust the government to spend my money wisely" it goes state > federal > local

For "I trust the government not to pass legislation that makes my life worse" it goes federal > local > state.

My local government is inept, corrupt and burns money like a German housewife in 1923 (A 100ft ladder truck when the tallest building is 3-stories, a boondoggle of a new highschool, a town run pet cemetery for Christ sake!!!) but mostly harmless.

My state government is hell bent on screwing over certain classes of people and passing laws that annoy everyone for political virtue points (and it is a 1-party state so there's no stopping them) but they mostly spend their money wisely.

The feds wrongly harm a lot of people (some violently, some not so violently) and aren't all that great with money but they're too gridlocked to enshrine any real stupidity in law.


Without knowing which state you live in I can tell this is so true. So much so that it make me wonder if there is a structural reason for this?


You know how some countries feel the need to prefix their name with the word "Democratic" and it's basically a guarantee that not much democracy is happening there. I feel the same way about the word "Commonwealth" when applied to US states. It's basically a dead giveaway that the government prioritizes itself above the common interest. I live in one of those states.


One of our two major parties has built its entire brand around mistrusting the government.


Speaking as an outsider - Did you see what their choice was last time around? I'm far from pro-Trump but it seems Hillary would have come with a whole different set of issues. Unfortunately it's the whole 2-party system that's broken.

I'm speaking as someone from a country with pretty much the same system (the UK). Voting for anyone other than the candidate you dislike the least is essentially a wasted vote. I and plenty of others in my country really wish we knew the answer (and so do many Americans, from what I've seen).

I'd be interested to hear where you are from. From what I know about Japan I gather that people are generally satisfied with their leadership. Maybe New Zealand as well?


Scotland (still part of the uk for now) has proportional representation rather than first past the post. This can help avoid the wasted vote idea.


Feels like a bad idea to me. Why not just tax the hell out of the private treatment to make sure the public treatments stay funded?

I guess the concern is similar to the public vs private school situation, where some areas have bad public schools because everyone with any money chooses a private school and has no incentive to fund the public system.

Still I find the idea of government-only medicine to be scary. In the past we've had politicians who have decided that things like abortion, stem-cell therapy, and medical marijuana were all moral evils. I am glad people had private options to get those things.


This is not proposing abolishing the private option. It is just establishing a distinction between private and public providers, so you don't constantly get pestered for topup fees.


Using the school analogy, imagine if schools had a private component and a public component. All kids got an education there, but there would be an incentive to charge more for a better education. And an incentive to blur the lines between what's a required fee and what is nickel and diming the parent.


> It will not allow participating institutions and providers to offer private care for covered services to the rich

I feel this is going to be a major talking point... Canada's system kinda works like this. Basic coverage with additional coverage you can purchase.


That's true, but not quite the same. There is one system and one payer for emergency care, as an example. You can't pay for additional or better care. However, eye glasses aren't covered by the public system. Additional coverage would help here.


That’s also how the uk works. Even there, it’s still possible to go to a completely private hospital for most things but generally not for true emergencies.


This bill is less about what it gives and more about what it takes away. Can they convince 155 million people to give up their employer-sponsored insurance for a government option?


I would in a heartbeat if it means more take-home pay and/or never having to think about which providers are "in network" again.


The chance that this will end up giving you the same level of care for less money is practically zero.


It depends.

Insurance companies are able to negotiate better rates as they get larger.


See pjc50's parallel comment to your own. You may still have to think about which providers are in the government plan.


That's not what's happening though; it's the providers who have to pick one or the other, not the public. Again, this sounds a lot like the UK system, where employer insurance exists but is genuinely a perk rather than something you need to survive.




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