The health care debate we ought to be having

https://www.axios.com/what-matters-2020-health-care-costs-7139f124-d4f7-44a1-afc2-6d653ceec77d.html

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Americans worry a lot about how to get and pay for good health care, but the 2020 presidential candidates are barely talking about what’s at the root of these problems: Almost every incentive in the U.S. health care system is broken.

Why it matters: President Trump and most of the Democratic field are minimizing the hard conversations with voters about why health care eats up so much of each paycheck and what it would really take to change things.

  • Instead, the public debate focuses on ideas like how best to cover the uninsured and the relative virtue of health care “choice.”

The U.S. spent $3.6 trillion on health care last year, and almost every part of the system is pushing its costs up, not down.

 

Hospitals collect the biggest piece of the health care pie, at about $1 trillion per year.

  • Their incentive is to fill beds — to send as many bills as possible, for as much as possible.
  • Big hospital systems are buying up smaller ones, as well as physician practices, to reduce competition and charge higher prices.
  • And hospitals have resisted efforts to shift toward a system that pays for quality, rather than volume.

 

Drug companies, meanwhile, are the most profitable part of the health care industry.

  • Small biotech companies usually shoulder the risk of developing new drugs.
  • Big Pharma companies then buy those products, market them aggressively and develop a fortress of patents to keep competition at bay as long as possible.

 

The money bonanza is enticing some nontraditional players into the health care world.

 

Insurers do want to keep costs down — but many of their methods are deeply unpopular.

  • Making us pay more out of pocket and putting tighter restrictions on which doctors we can see create real and immediate headaches for patients.
  • That makes insurers the most convenient punching bag for politicians.

 

The frustrating reality: Democrats’ plans are engaging in the debate about possible solutions more than the candidates themselves.

  • It’s a tacit acknowledgment of two realities: That controlling the cost of care is imperative, and that talking about taking money away from doctors and hospitals is a big political risk.

 

What they’re saying: The top 2020 Democrats have actually released “insanely aggressive” cost control ideas, says Larry Levitt, executive vice president at the Kaiser Family Foundation. “But they don’t talk about that a lot.”

  • Medicare for All, the plan endorsed by Sens. Bernie Sanders and Elizabeth Warren, would sharply reduce spending on doctors and hospitals by eliminating private insurance and paying rates closer to Medicare’s. Estimates range from about $380 billion to nearly $600 billion in savings each year.
  • Joe Biden and Pete Buttigieg have proposed an optional Medicare-like insurance plan, which anyone could buy into. It would pay providers less than private insurance, with the hopes of putting competitive pressure on private plans’ rates.
  • The savings there would be smaller than Medicare for All’s, but those plans are still significantly more ambitious than the Affordable Care Act or most of the proposals that came before it.

 

Yes, but: The health care industry has blanketed Iowa with ads, and is prepared to spend millions more, to defend the very profitable status quo.

  • The argument is simple: Reframe the big-picture debate about costs as a threat to your doctor or your hospital. It’s an easy playbook that both parties, and the industry, know well. And it usually works.

 

The bottom line: “Voters want their health care costs reduced, but that doesn’t mean they would necessarily support what it would take to make that happen,” Levitt said.

 

 

 

 

The most expensive health care option of all? Do nothing.

https://www.politico.com/news/2020/01/09/medicare-for-all-health-care-096367?utm_source=The+Fiscal+Times&utm_campaign=b67cf54986-EMAIL_CAMPAIGN_2020_01_09_10_31&utm_medium=email&utm_term=0_714147a9cf-b67cf54986-390702969

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‘Medicare for all’ debate sidesteps cost of current system.

The projected multitrillion-dollar cost of “Medicare for All” has pitted Democratic presidential candidates against each other as they argue about the feasibility of single-payer health care.

But the reality is the current health system may cost trillions more in the long run and be less effective in saving lives.

Spending on Medicare, Medicaid, private health insurance and out-of-pocket expenses is projected to hit $6 trillion a year — and $52 trillion over the next decade. At the same time, the number of people with insurance is dropping and Americans are dying younger.

Sen. Bernie Sanders and other single-payer advocates say Medicare for All would cost the government far less — between $20 trillion and $36 trillion over a decade — by slashing overhead, eliminating out-of-pocket costs and empowering federal officials to bargain directly with hospitals and drugmakers. But the streamlined system would have to care for millions of currently uninsured people at a significant cost to taxpayers, and experts disagree whether it would actually save money in the long run.

Centrist Democrats are pushing narrower plans that would, among other things, expand tax credits for people just above the Obamacare subsidy threshold. Virtually no one is arguing for maintaining the status quo, but that’s precisely what could happen given that congressional gridlock has stymied even popular, and bipartisan, causes like halting surprise medical bills.

“It’s really hard to see anything breaking through, especially when the industry interests and the money they’re willing to spend on lobbying and campaign contributions is just mind-boggling,” said Sabrina Corlette, a researcher at Georgetown University’s Center on Health Insurance Reforms. “And, without question, we are on an unsustainable trajectory.”

With Medicare for All and its price tag likely to come up in the next Democratic debate Jan. 14 in Iowa, here are five of the costliest consequences of inaction:

National health spending keeps rising

The Centers for Medicare and Medicaid Services estimates that nationwide health spending will hit $6 trillion a year by 2027 absent any changes in law. That would be nearly a fifth of the economy. In total, the United States is slated to spend about $52 trillion over the coming decade.

The cost drivers include hospitals, physician and clinical services and prescription drugs. Some local health systems have become monopolies that can largely set prices as they please — leading to higher premiums and more out-of-pocket spending for consumers.

“Even the biggest insurance plans are not big enough to bargain down the cost of services, and they don’t have an incentive to,” said Wendell Potter, a former Cigna executive-turned whistleblower and single-payer advocate.

An aging population is driving up Medicare spending, but the rising cost of private insurance is the biggest factor. A recent Kaiser Family Foundation analysis found per capita spending for private insurance grew by nearly 53 percent over the last decade, or more than double the hike in per capita Medicare spending.

More people will be uninsured

The Census Bureau reported in September that the number of Americans without insurance grew by 2 million people since 2017 — the first increase in nearly a decade. Even with a healthy economy and low unemployment, more than 27 million people weren’t covered at any point last year. That could grow to 35 million by 2029, per the Congressional Budget Office, under current law.

The number of people enrolling in the Obamacare marketplace has declined, and more people are dropping employer-sponsored insurance due to cost and other concerns.

Part of this is President Donald Trump’s doing — the administration has slashed efforts to push Obamacare enrollment and rolled back the massive marketing effort that the Obama administration rolled out for years.

There are also more than 400,000 additional uninsured children than just two years ago — and 4 million in all — and states that haven’t expanded Medicaid are seeing the biggest spikes.

“What we also miss in the debate is the number of people temporarily uninsured, who miss open enrollment, who are between jobs, who fall through the cracks,” said Adam Gaffney, a Harvard Medical School researcher and the president of Physicians for a National Health Program. “I see people all the time in my practice in that situation who don’t fill prescriptions and experience serious complications.”

Going without insurance hits patients and health care providers: Average hospital spending on care for the uninsured was $13 million in 2018 up roughly 3 percent annually since 2016.

Coverage will be skimpier

As the cost of health care has skyrocketed, insurance companies have squeezed patients, charging higher premiums, deductibles and co-pays, and creating narrow networks of providers and aggressively billing for out-of-network care.

Since 2009, the amount workers have had to pay for health insurance has increased 71 percent, while wages have only risen 26 percent over that time.

More than 80 percent of workers now have to pay a minimum amount out of pocket before insurance kicks in — and the amount of that deductible has doubled over the last 10 years, now standing at an average of $1,655, though many workers have to pay a lot more.

These costs are putting care out of reach for millions.

new Gallup poll found that a full quarter of adults have put off treatment for a serious medical condition due to the cost — the highest since Gallup began asking the question three decades ago. A full third say they’ve delayed or deferred some kind of health care service over the past year. Another Gallup and West Help survey found that 34 million people know at least one friend or family member who died over the past five years after skipping treatment due to costs.

 

Needed drugs will become more out of reach

U.S. patients pay vastly more for prescription drugs than people in other developed countries and the disparity is set to grow. The United States spent $1,443 per person on prescription drugs in 2018, while other developed countries fell somewhere between $466 and $939.

In just five years, national spending on prescription drugs increased 25 percent, according to the Government Accountability Office, and CMS expects that increase to “accelerate” over the next several years.

Increasingly, patients are responding by forgoing their medications. Gallup found in November that nearly 23 percent of adults — roughly 58 million people — said they haven’t been able to “pay for needed medicine or drugs that a doctor prescribed” over the past year.

This widespread inability to take needed medication, a government-funded study found last year, is responsible for as much as 10 percent of hospital admissions. And the Centers for Disease Control and Prevention estimates that medication nonadherence accounts for somewhere between $100 and $300 billion in national health spending every year.

 

Americans will continue to get sicker and die younger

The cost of maintaining the status quo is evident not only in dollars but in human lives.

Life expectancy in the United States has declined over the last three years, even as other developed countries around the world saw improvements.

Though the United States spends nearly twice as much on health care as other high-income countries, there’s been a stark increase in mortality between the ages of 19 and 64, with drug overdoses, alcohol abuse, suicide and organ diseases driving the trend. It’s cut across race and gender with the worst effects felt in rural areas.

The opioid epidemic only accounts for a fraction of the problem. The National Research Council found that the United States has higher mortality rates from most major causes of death than 16 other high-income countries.

Researchers at USC estimate that if these trends continue, it would take the United States more than a century to reach the average life expectancy levels other countries hit in 2016.

 

 

Medicare for All’s missing mental health discussion

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Illustration of a health plus on a therapist couch.

America’s mental health care system is in dire need of an overhaul, but the real specifics are largely missing from the 2020 debate about health care.

Why it matters: Suicide and drug overdose rates continue to rise, and the U.S. faces a shortage of mental health providers and a lack of access to treatment.

The big picture: Private insurance is plagued with holes in mental health coverage. Even even though insurers are legally required to cover behavioral health the same way as physical health, they don’t.

Yes, but: “Medicare to All” may not solve the problem, Mental Health America president and CEO Paul Gionfriddo told me.

  • “Medicare would need to be redesigned significantly,” he said.
  • Medicare has its own coverage flaws. It would also be crucial to design a system that encourages preventive and early identification services rather than just post-crisis care.

There’s also a shortage of mental-health providers. Paying mental health providers more could help address this, but care delivery would also need to be redesigned, Gionfriddo said.

  • Rural areas, for example, would likely still struggle to attract and support these providers because of their remoteness and population size.
  • The big wild card is how many mental health providers would participate in a Medicare for all program or opt out of insurance entirely,” said the Kaiser Family Foundation’s Larry Levitt.

For Democrats who support Medicare for All, highlighting how it could help mental health care could have a political upside.

  • Talking about mental health care needs humanizes the candidates, indicts the shortcomings of private insurance and provides rationale for the need for significant reforms around the current system,” Democratic health consultant Chris Jennings said.

 

 

 

Pros and Cons of Different Public Health Insurance Options

https://www.commonwealthfund.org/publications/journal-article/2018/nov/pros-cons-public-options-2020-democratic

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Options for Expanding Health Care Coverage

It is more than likely that Democratic candidates for the 2020 presidential election will propose some type of public health insurance plan. In one of two Commonwealth Fund–supported articles in Health Affairs discussing potential Democratic and Republican health care plans for the 2020 election, national health policy experts Sherry Glied and Jeanne Lambrew assess the potential impact and trade-offs of three approaches:

 

  • Incorporating public-plan elements into private plans through mechanisms such as limits on profits, additional rules on how insurers operate, or the use of Medicare payment rates.
  • Offering a public plan — some version of Medicare or Medicaid, for example — alongside private plans. Such a plan could be offered to specific age groups, like adults 50 to 64 who are not yet eligible for Medicare, to enrollees in the Affordable Care Act’s (ACA) marketplaces, or to everyone under 65, including those working for self-insured employers. It also could be made available in regions of the country where there is little health care competition.
  • Replacing the current health care financing system with a “Medicare for all” single-payer system administered by the federal government. Some single-payer proposals would allow consumers to purchase supplementary private insurance to help pay for uncovered services.

 

Issues for Consideration in 2020

The authors find trade-offs in each type of public plan. First, a single-payer system would significantly increase the federal budget and require new taxes, a politically challenging prospect. On the other hand, federal spending might decrease if a public plan were added to the marketplace or if public elements were added to private plans. In 2013, the Congressional Budget Office estimated that a public plan, following the same rules as private plans, would reduce federal spending by $158 billion over 10 years, while offering premiums 7 percent to 8 percent lower than private plans. A single-payer approach would lower administrative costs and profits, and likely reduce health care prices as well. By assuming control over the financing of health care, the federal government could reduce administrative complexity and fragmentation. On the flip side, the more than 175 million Americans who are privately insured would need to change insurance plans.

 

public–private choice model would help ensure that an affordable health plan option is available to Americans. While politically appealing, this option presents implementation challenges: covered benefits, payment rates, and risk-adjustments all need to be carefully managed to ensure a fair but competitive marketplace. A targeted choice option might be adopted by candidates interested in strengthening the ACA marketplaces in specific regions or for specific groups (as with the Medicare at 55 Act). It would benefit Americans whose current access to affordable coverage is limited, but the same technical challenges associated with a more comprehensive choice model would apply.

 

Finally, to lower prices for privately insured individuals, public plan tools such as deployment of Medicare-based rates could be applied to private insurance, either across the board or specifically for high-cost claims, prescription drugs, or other services. The major challenge here is setting prices that would appropriately compensate providers.

 

The Big Picture

Under the ACA, the percentage of Americans who had health insurance had reached an all-time high (91 percent) in 2016, an all-time high, and preexisting health conditions ceased to be an obstacle to affordable insurance. But Americans remain concerned about high out-of-pocket spending and access to providers, and fears over losing preexisting-condition protections have grown. While most Democratic presidential candidates will likely defend the ACA and seek to strengthen it, most recognize that fortifying the law will not be enough to cover the remaining uninsured, rein in rising spending, and make health care more affordable.

 

While the health reform proposals of Democratic candidates in 2020 will likely differ dramatically from those of Republican candidates, recent grassroots support for the ACA’s preexisting condition clause may indicate a willingness by both political parties to support additional government intervention in private insurance markets.

 

 

 

Five health care fights to watch in 2020

https://thehill.com/policy/healthcare/475575-five-health-care-fights-to-watch-in-2020

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Advocates hope lawmakers can beat the odds and move major health care legislation in the new year.

2019 opened with bipartisan talk of cracking down on drug prices and surprise medical bills. But it ended without major legislation signed into law on either front, and a host of other health care battles, including a lawsuit threatening the entire Affordable Care Act, looming over the coming election year.

Here are five health care fights to watch in 2020. 

 

Drug pricing

Lowering drug prices was supposed to be an area for potential bipartisan action in 2019, but the effort ran into a brick wall of industry lobbying and partisan divisions. 

There is a push to finally get legislation over the finish line in 2020, though.

Speaker Nancy Pelosi (D-Calif.) is calling for attaching drug pricing legislation to a package of expiring health care programs, like community health center funding, that must be renewed by May 22. She hopes the pressure from that deadline helps carry a larger package, but that is far from certain, especially as the election gets closer.

Democrats point to President Trump’s vow to support allowing the government to negotiate drug prices during his 2016 campaign. While Trump backed off that pledge this year, they hold out hope he might come back around. Senate Majority Leader Mitch McConnell (R-Ky.) is also strongly opposed to the idea, and has concerns about a more modest bill from Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.) that could provide a more realistic bipartisan path.

“The president said when he ran and until relatively recently that he would support negotiated prices and I expect at some point he will go back to that, and we’re just going to keep pushing the Senate to try to achieve that,” said House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.).

 

Surprise billing

The other major health care initiative that Pelosi says she wants in the May package is protecting patients from surprise medical bills.

That effort has also fallen prey to intense industry lobbying and congressional infighting. 

Backers of a bipartisan bill from the House Energy and Commerce Committee and Senate Health Committee on the issue pushed for including the measure in a year-end spending and were deeply frustrated when it was left out.

A key factor was House Ways and Means Committee Chairman Richard Neal (D-Mass.) putting forward the outline of a rival plan days before this month’s funding deadline, showing a split on the way forward.

“It’s certainly going to be harder [next year],” said Shawn Gremminger, senior director of federal relations at Families USA, a liberal health care advocacy group.

“You are now under six months out from the general election,” he said about moving legislation in May 2020.

Backers have a tough road ahead. They will have to bridge the divide between the competing plans and overcome lobbying from powerful doctor and hospital groups, who worry the legislation could lead to damaging cuts to their payments.

 

ObamaCare

Outside of Capitol Hill negotiating rooms, the GOP lawsuit to overturn the Affordable Care Act is looming large. 

A federal appeals court last week issued a long-awaited ruling on the fate of the law, though it did little to settle the issue. The 5th U.S. Circuit Court of Appeals ruled that the law’s mandate to have health insurance is unconstitutional, but punted on the question of whether any of the rest of the law should also be struck down, instead sending it back to the lower court.

The most tangible effect of the move could be to push a final Supreme Court decision on the fate of the law past the 2020 elections, though it’s possible the justices could still choose to take the case sooner.

Democrats intend to hammer Republicans over the lawsuit during next year’s campaign, though, a strategy that paid off for the party during the 2018 midterms when they focused on health care. 

The Democratic group Protect Our Care launched a national TV ad on Friday, saying “President Trump and Republicans just won a major decision in their lawsuit to repeal health care from millions of American families,” and warning of the loss of pre-existing condition protections.

 

Medicare for All 

In the Democratic presidential race, “Medicare for All” is a central dividing line.

How the issue plays out in 2020 will depend in large part on who wins the Democratic nomination. If progressives like Sens. Bernie Sanders (I-Vt.) or Elizabeth Warren (D-Mass.) win the nomination, Republicans will be able to go full bore on their attacks that private health insurance would be eliminated under the proposal.

Even more moderate candidates like former Vice President Joe Biden and South Bend, Ind., Mayor Pete Buttigieg PETER (PETE) PAUL BUTTIGIEGPoll: Biden remains ahead of Sanders by 10 points2020 predictions: Trump will lose — if not in the Senate, then with the votersButtigieg’s former chief of staff to be sworn in as mayoral successorMORE would face attacks that their public option plans are a step down the road toward eventually implementing full-scale single payer.

The internal debate on the issue has faded somewhat from its peak. Health care has not featured as prominently in the last two debates, and some of the fighting has shifted to other areas, like candidates’ fundraising practices.

But the issue is still simmering and could burst back to open warfare among Democrats at any point.

 

Vaping

The battle over e-cigarette flavors will likely resume in 2020 as the Trump administration and Congress try to cut rising youth vaping rates.

Public health advocates are pushing the administration to clear the market of flavors like mint and fruit that they argue are fueling a youth vaping epidemic.

Trump said he would eliminate those flavors in September, but has appeared to back down after backlash from vaping advocates and the e-cigarette industry.

Now he says he would like to find a compromise that preserves such flavors for adults while keeping them away from kids.

Advocates like the Campaign for Tobacco-Free Kids plan to pressure Trump to follow through on his word, though it’s looking unlikely.

However, the e-cigarette market could also look vastly different after May 2020, when companies must apply to the Food and Drug Administration to stay on the market

The industry must prove its products benefit public health, a big ask for companies like Juul, whose products are favored by kids who vape.

House Democrats also plan to vote on a bill that would ban flavored e-cigarette and tobacco products, but it’s not clear if it will get a vote in the Senate.

 

Democrats double down on health care prices

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Illustration of price tag stickers in the shape of a health plus.

Many 2020 Democrats’ health care proposals feature aggressive price regulations, either as a feature or a byproduct — a sign the party has largely given up on the idea that competition alone can keep costs in check.

Between the lines: It’s not just Democrats. As public outrage has grown over prescription drug prices and surprise medical bills, there’s been bipartisan congressional interest in regulating prices.

The two big trends are increasing out-of-pocket costs to consumers and increasing disparity between public and commercial rates — and therefore consumer and employer pushback on those dynamics — and policymakers are now attempting to respond.”

— Chris Jennings, a Democratic health care consultant

The big picture: “Medicare for All” brings all provider and drug reimbursements under the federal government’s control.

  • Sen. Bernie Sanders has been elusive about what those rates would be, but Sen. Elizabeth Warren has proposed massive rate cuts to doctors and hospitals as a way to reduce her plan’s cost.

Even the more moderate candidates’ public-option plans would enroll more Americans in government health care plans that set rates. And some have pitched ideas like limiting how much providers can charge for out-of-network care.

  • But supporters of a public option argue that it also enhances competition in the private insurance market, driving prices down across the board without completely abandoning the use of market forces.

All of the leading 2020 candidates have proposed drug policies, ranging from limiting how much drug companies can increase their prices to allowing the federal government to strip the patent from drugs that are deemed too expensive.

  • Even President Trump has proposed limiting how much Medicare pays for certain drugs by tying the price to what other countries pay.

The other side: The industry hates all of these ideas.

 

 

 

Medicare for All’s jobs problem

https://www.politico.com/news/agenda/2019/11/25/medicare-for-all-jobs-067781?utm_source=The+Fiscal+Times&utm_campaign=ae11965f63-EMAIL_CAMPAIGN_2019_11_26_10_44&utm_medium=email&utm_term=0_714147a9cf-ae11965f63-390702969

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The big Democratic talking point has a big political weakness: It could wipe out thousands of jobs in places like Pittsburgh that have built their new economies on health care.

Deanna Mazur, the daughter of a retired steel mill worker who works as a medical billing manager, finds some things to like about the “Medicare for All” policy that she’s been hearing politicians talk about. She likes the notion that all Americans would have health insurance. And it would simplify her own job quite a bit if there were only one place to send medical bills, instead of the web of private companies and government programs that she deals with now. “It would definitely be easier,” Mazur says.

Then again, if it were that easy, her job might not exist at all.

Mazur’s job and those of millions of others have helped turn health care into the largest sector of the nation’s economy, a multitrillion-dollar industry consisting in part of a huge network of payers, processers, and specialists in the complex world of making sure everything in the system gets paid for. If the health care system were actually restructured to eliminate private insurance, the way Medicare for All’s advocates ultimately envision it, a lot of people with steady, good-paying jobs right now might find themselves out of work.

“What if my job doesn’t exist anymore?” she asked in a recent interview.

This question has particular resonance in this part of Pennsylvania, a must-win swing state in the presidential race, which has already seen massive job dislocation from the decline of manufacturing. As Pittsburgh’s iconic steel industry has been gutted, the city’s economy has been hugely buoyed by health care, which has grown into the region’s largest industry — employing about 140,000 people, or 20 percent of the regional workforce. The city’s former U.S. Steel complex is now, appropriately enough, the headquarters of a mammoth hospital system, one of two health care companies deeply entrenched in the city’s economy.

There are lots of health reform ideas that wrap themselves in the “Medicare for All” label, ranging from a single government-run system to plans that maintain a role for private insurance companies. But under the most ambitious schemes, millions of health care workers would be at least displaced if not laid off, as the insurance industry disappears or is restructured and policymakers work to bring down the costs of the system by reducing high overhead and labor costs. The reform proposals being promoted by Democratic presidential candidates have barely grappled with this problem.

Initial research from University of Massachusetts economists who have consulted with multiple 2020 campaigns has estimated that 1.8 million health care jobs nationwide would no longer be needed if Medicare for All became law, upending health insurance companies and thousands of middle class workers whose jobs largely deal with them, including insurance brokers, medical billing workers and other administrative employees. One widely cited study published in the New England Journal of Medicine estimated that administration accounted for nearly a third of the U.S.’ health care expenses.

Even if a bigger government expansion into health care left doctors, nurses, and other medical professionals’ jobs intact, it would still cause a restructuring of a sprawling system that employs millions of middle-class Americans.

Claire Cohen, a Pittsburgh-based child psychiatrist, voted for Bernie Sanders, the architect of the most sweeping version of Medicare for All, in the 2016 Democratic presidential primary. She says the national discussion about single payer and its overwhelming focus on paying higher taxes or losing private insurance misses the point ― she argues individuals would see greater benefit from a health care system without premiums, copays and other costs that increasingly make health care out of reach. But the question about jobs, she says, is a “legitimate” issue ― one she says people haven’t completely thought through.

“You don’t want to leave all these people in the lurch without jobs,” Cohen said.

Having it both ways

The idea of one national health plan covering all Americans has steadily grown more popular in public opinion polls over time, a sea change that coincides with Medicare for All becoming near orthodoxy for progressive Democrats. Prior to 2016, when Sanders made it the linchpin of his insurgent run for president, less than half of Americans supported setting up a such a system, according to Kaiser Family Foundation polling. Now, just over half of the public backs it.

When it comes to the costs of reform, taxes are the headline issue, and the movement’s advocates on the national stage ― Sanders and fellow Democratic presidential contender Elizabeth Warren, among others ― have largely had to defend Medicare for All against charges that middle-class taxes would have to go up to finance a new government-run system. But the question of what single-payer health care would do to jobs and the economy has largely been overlooked. In the past, Sanders has answered questions about the economic ramifications with vague claims about transitioning to other jobs in the health sector.

“When we provide insurance to 29 million people who today don’t have it, when we deal with the problems of high deductibles and copayments and more people get the health care that they want and they need, weʼre going to have all kinds of jobs opened up in health care,” Sanders claimed during a 2016 CNN town hall when asked by a retired health insurance worker what would happen to jobs in the industry. “And the first people in line should be those people who are currently in the private health insurance industry.”

Economists dispute the extent to which this would occur. Robert Pollin, co-director of the Political Economy Research Institute at the University of Massachusetts-Amherst who has consulted with Sanders’ and Warren’s teams over Medicare for All, says that while people could be retrained for different jobs, there are no guarantees they’d work in the newly created government health care system, since one of the goals is to cut down on administrative overhead. “You can’t have it both ways. You can’t have savings through administrative simplicity and more jobs. The government won’t need these people,” Pollin said.

Health care workers are interwoven throughout the economy, employed by large institutions like hospitals, health insurance companies and nursing homes but also in places like small accounting firms that help clinicians get reimbursed for care, and as independent brokers who help sell insurance products to customers.

Mazur handles medical billing for physicians through Medicare, Medicaid and private insurance, the last of which is the most complicated. Under Medicare for All, “They don’t have to worry about, am I going to get paid for this service based on what insurance the patient has? It would be the same rules for everybody.”

In Pittsburgh, workers in the health care economy interviewed for this article weren’t necessarily against a single-payer system, even if it meant their work would be personally affected. But they did consistently say that Democratic candidates for president need to make the employment implications clearer.

Marc Schermer, a Pittsburgh-based insurance broker who sells health plans to individual customers as well as small businesses, says he’d likely experience a temporary setback but believes he’d manage since he sells other kinds of insurance, too. He even thinks single payer is an idea “he could get behind” because removing private insurance companies from the system would simplify things.

“I’m pretty well diversified so that if suddenly the ‘Medicare for All’ thing happened, and companies like United and Highmark and UPMC and Aetna were brushed aside, I would still have something to do,” Schermer said. “But there are a lot of people who are employed directly by those companies who would be up a creek.”

Medicare for All isn’t predicted to disrupt all job types and could even potentially benefit certain types of health care workers ― for example, by expanding the need for caregivers because of a proposed expansion of long-term care benefits. And Medicare for All would provide health benefits to tens of millions who are still uninsured, creating additional demand for doctors and other providers. Still, others are likely to be lost in the short term.

“We vilify the health care industry, but it provides jobs to a lot of people, and not just jobs for wealthy people but jobs for everyday people,” said Janette Dill, a researcher at the University of Minnesota who has studied the rise of health care-related employment among the working class. “That’s one thing it’s really good at.”

Health care jobs in Allegheny County, the region surrounding Pittsburgh, grew from roughly 90,000 in 1990 to around 140,000 this year, according to the Pennsylvania Department of Labor and Industry. Another 9,500 people work directly for health insurance companies and about 3,200 work for insurance agencies or brokerages, which includes people who sell health insurance policies.

The power of the health care industry in southwestern Pennsylvania is inescapable. Hospitals and clinics controlled by two competing health care behemoths, the University of Pittsburgh Medical Center and Highmark Blue Cross Blue Shield, dot Pittsburgh’s streets. The two companies have slowly moved in on the other’s territory and saturated Pittsburgh’s health care market, with the iconic UPMC brand operating a health insurance arm, and Highmark BCBS running the Allegheny Health Network system of hospitals and clinics.

Both companies declined to comment on the potential impact of Medicare for All on their workforces.

University of Massachusetts researchers who analyzed the 2017 version of Sanders’ Medicare for All bill estimated that nationwide more than 800,000 people who work for private health insurance companies and a further 1 million who handle administrative work for health care providers would see their jobs evaporate.

The workers generally earn middle-class wages, according to the November 2018 study forecasting the economic ramifications of Sanders’ plan. The median annual income of a worker employed in the health insurance industry is nearly $55,000; for office and administrative jobs at health care service sites, it’s about $35,000, researchers said.

“The savings don’t come out of the sky,” said Pollin. “The main way we save money is through administrative simplicity. That means layoffs. There’s just no way around it.”

Extra dollars, extra life?

Of course, the larger problem behind the question of job losses is just how much of the U.S. economy should be devoted to health care.

Economists say there isn’t a magic number for how large or small the health care sector should be. But they often express concern that the U.S. gets too little benefit for the amount of money it spends, with spending levels twice that of many other developed nations and actual health outcomes significantly lower. Much of that money goes to overhead, in the form of middlemen like insurers and the surrounding industries.

“The problem is you’re spending extra dollars right now, and it’s not at all clear you’re getting extra life for it,” said Katherine Baicker, a health care economist and dean of the University of Chicago’s Harris School of Public Policy.

Cutting those excess costs has appeal to economists, who prioritize efficiency and value for money. But politically it can be a challenge when what looks like an “excess cost” from a distance looks like a good-paying job to the person who holds it. Nationally, the growing health care sector was an economic bright spot even during the Great Recession, continuing to add jobs while others shed millions of workers, according to an analysis from the Bureau of Labor Statistics.

Medicare for All also wouldn’t be the first, nor likely the last, initiative that would cause economic upheaval for a major jobs engine. Baicker argues that the jobs piece isn’t a metric that people should use to judge whether single payer is worth it, because in a dynamic economy different sectors grow while others shrink.

“What you need is transition help for those people whose sectors are shrinking,” Baicker said. We may all be better off in the long run when we can produce all the food we need with many fewer people working in agriculture … that doesn’t mean that you can instantaneously turn a farmer into a software engineer or a nurse into a financial expert.”

There’s some precedent for federal programs that help individuals whose jobs have been upended because of broader economic policy decisions, including the Trade Adjustment Assistance program that helps workers displaced by global trade.

The latest Medicare for All bills in the House and Senate, championed by members in Democrats’ most liberal wing, include provisions addressing assistance for displaced workers. The House version spearheaded by Rep. Pramila Jayapal, a Democrat from Washington state, mandates that for up to five years at least 1 percent of the new health care program’s budget will be spent on efforts to prevent dislocation for health insurance administrative workers or individuals who perform related work at health care organizations.

“This happens every time there’s innovation,” said Jayapal, who co-chairs the House’s Progressive Caucus. “It happens with Lyft and Uber. It happens with movie cameras instead of still photographs. This is part of what happens as you make things better.”

Sanders’ legislation appears to be more limited. The bill allows — but doesn’t require ― that such assistance be provided to workers and caps the amount at 1 percent.

Even in Pittsburgh, not everyone is worried that a national health care law would gut the area’s leading industry yet again. When manufacturing declined in the 1980s in the region, “nobody really cared” and workers were just told to “suck it up” in response to job loss, said Ed Grystar, a longtime union organizer and chair of the Western PA Coalition for Single-Payer Healthcare.

Grystar, who says he spent most of his life negotiating contracts for nurses, says Medicare for All represents a “monumental shift for social justice” to help people access something they deserve. The current system, with its out of control prices and dysfunction, “can’t go on.”

As for the insurance jobs?

“Who cares if [insurance companies] go out of business?’’ Grystar said in an interview. “This is a net positive for society as a whole.”