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This Tweet Captures the State of Health Care in America Today
A nightmarish accident on a Boston subway platform on Friday — described in gory detail by a local reporter, Maria Cramer, as it unfolded and quickly retweeted by thousands — is one you might expect to see in an impoverished country.
In the face of a grave injury, a series of calculations follow: The clear and urgent need for medical attention is weighed against the uncertain and potentially monumental expense of even basic services, like a bandage or a ride to the hospital, and that cost, in turn, weighed against all the known expenses of living that run through any given head on any given day.
This discord, between agony and arithmetic, has become America’s story, too.
The United States spends vastly more on health care than other industrialized countries, nearly 17 percent of the nation’s gross domestic product in 2014, according to a report by the Commonwealth Fund, compared with just 10 percent of G.D.P. in Canada and Britain. But that disparity is not because Americans use more medical services — it’s because health care is far more expensive here than in other countries. One 2010 study by the Organization for Economic Cooperation and Development found that hospital costs were 60 percent higher in the United States than in 12 other nations.
And that cost is often passed on to patients, either in the form of deductibles and other out-of-pocket expenses or through ever-soaring insurance premiums.
The Affordable Care Act has improved access to health care, especially for lower-income families that now qualify for Medicaid or subsidies to buy private health insurance. Wider access, however, has not come cheaply for most people. As a result, many Americans, including those who are insured, have determined that they must avoid going to the hospital, visiting doctors or filling prescriptions that they need. A 2017 Kaiser Family Foundation survey found that 43 percent of people with insurance said that they struggled affording their deductibles, and 27 percent said that they put off getting care because of cost. Turning to GoFundMe and other crowdsourcing websites has become the norm in medical crises.
Whether the woman on the train platform received the medical attention she needed is unknown. Ms. Cramer said on Monday that she had not been able to get an update on the woman’s condition yet. Ms. Cramer went on to tweet that after several minutes had passed, an ambulance still had not arrived. Instead, fellow passengers tried to help. “One man stood behind her so she could lean against him,” she wrote. “Another pressed cold water bottles to her leg.”
Health care is a complicated problem, one exacerbated by the gridlock in Washington. But the trade-offs that everyday people are being asked to make, the calculations they are being forced to undertake in the scariest of situations, suggest that far too many of America’s politicians have placed too little value on the well-being of its citizens. Nothing will change until their fellow citizens step into the ballot box and insist on something better.
The “pleasant ambiguity” of Medicare-for-all in 2018, explained
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Are we talking about single-payer health care or something else?
Democrats across the country are running on three simple words, recognizable to every American: Medicare for all.
“There’s no more popular brand in American politics than Medicare,” says Adam Green, co-founder of the lefty Progressive Change Campaign Committee (PCCC). “Our hope is that Democrats wrap themselves in the flag of Medicare in 2018.”
In Democratic primaries around the country, Medicare-for-all candidates are winning — from Kara Eastman in Nebraska to Katie Porter in Orange County, California, to Alexandria Ocasio-Cortez in the Bronx, the message is resonating.
“The system we have, the status quo is not acceptable,” Porter told me when I covered her primary race in May. “We’re questioning whether we can rely on major players, like health insurance companies, to continue to be reliable partners in delivering health care.”
Even before these candidates started winning, polling was showing that Medicare-for-all is really popular: 62 percent of Americans liked the sound of it in last November. Almost every single rumored 2020 candidate in the Senate has backed Sen. Bernie Sanders’s Medicare-for-all bill. It’s clear the idea is in ascendancy among Democrats.
But someday, a reckoning will come. When Democrats hold power again — especially control of Congress and the White House — they will be expected to actually deliver on these Medicare-for-all promises. And when that day arrives, the party will have to decide whether they want to blow up America’s current health care system to build something new or figure out a less disruptive path, but risk falling short of truly universal coverage.
So even now, there is some jockeying among Democrats to define those three little words.
What does “Medicare-for-all” actually mean?
As popular as Medicare-for-all is, the slightly more vexing question is what it actually means.
Historically, Medicare-for-all has meant single-payer health insurance, a national government-run program that covered every American and replaced private coverage entirely, similar to the government-run health care programs in Canada and some European countries.
Then-Rep. John Conyers (D-MI) first introduced the Expanded and Improved Medicare for All Act in 2003. Conyers has since been disgraced by sexual harassment allegations but the idea lives on. It’s now sponsored by Rep. Keith Ellison (D-MN) and it is still a single-payer proposal. So is Sanders’s Medicare-for-all bill, a cornerstone of his unexpectedly resonant 2016 presidential campaign.
But these days, other plans are falling under the Medicare-for-all umbrella. Some progressives, like Green, are even comfortable with the term being applied to the various proposals to allow all Americans buy into Medicare. Some of those plans used to be branded as a “public option”; they would not end private insurance that more than half of Americans get, usually through work, as a true single-payer would. But these plans would also not provide the same guarantee of universal coverage that a single-payer system does.
“For anybody who supports Medicare-for-all single payer, what better way to debunk the right wing lies than to allow millions and millions of Americans to voluntarily opt into Medicare and love it?” Green told me in our interview. “As a political strategy, having Medicare-for-all be a broad umbrella where any candidate can embrace some version of it… that moves the center of gravity in the Democratic party.”
In 2018, with control of Congress at stake, nobody is taking up arms to insist that their version should be orthodoxy. What we know for certain is that Medicare-for-all is popular, and so Democrats of all stripes want to campaign on it. Governing comes later.
What does the public think about Medicare-for-all versus single-payer health care?
Ultimately, the direction the Democratic party goes in may have a lot to do with how far the public is willing to go.
One chart from the Kaiser Family Foundation, the gold standard for health policy polling, sums up why there is any debate at all about the meaning of Medicare-for-all.
Medicare-for-all gets nearly two-thirds support, but a “single-payer health insurance system” is a little more divisive: 48 percent have a positive reaction, and 32 percent have a negative reaction; the gap between favor and disfavor closes considerably. Medicare buy-ins poll the highest, with the support of three-fourths of Americans, including 6 out of 10 Republicans.
You could absolutely argue these numbers still seem pretty strong for single-payer described as such, given the conventional wisdom that such a plan is unworkable. But it is undoubtedly true that Medicare-for-all, as a slogan, is more popular — as are some of these more incremental policies, like giving people the option of buying into Medicare.
The “pleasant ambiguity” of Medicare-for-all, explained
Back in 2012, a group of progressive activists and Democratic lawmakers got together to talk about what they would do if the Supreme Court ruled the Affordable Care Act unconstitutional. That looked like a real possibility, and they agreed on a new campaign to keep pushing for universal health care.
Democrats planned to run on a platform of Medicare-for-all if the Court struck the law down. At that point, the Conyers single-payer bill had been around for nearly a decade, but the PCCC’s Green says that on that day and in that room, some people heard Medicare-for-all and thought of a single-payer system. Yet others heard the same thing and thought of something that looks more like a public option. From his perspective, those different ideas aren’t a problem.
“There is a pleasant ambiguity and more of a north star goal nature around Medicare-for-all,” Green said. “This really does not need to be a huge intra-party battle. Why get in the weeds during the campaign?”
Voters themselves seem to like the sound of Medicare-for-all, even if they themselves don’t always agree on what it means. BuzzFeed’s Molly Hensley-Clancy reported on this phenomenon while covering Eastman’s campaign in Nebraska ahead of the May primary:
[C]onversations with more than two dozen Omaha voters reveal a dynamic that polling, too, has begun to capture: When some moderate and left-leaning voters say “Medicare for All” sounds like a pretty good idea, they aren’t actually thinking about single-payer health care. Instead, they’re thinking about simply expanding the program to include more seniors or children, or offering a public option that people can buy into.
On one warm May day a week from the primary, Phil, a devout liberal, told Eastman the story of his wife’s brain cancer — rejected by Medicaid, and still too young for Medicare, they’ve barely been able to afford pricey experimental treatments.
He likes the sound of Medicare for All, he said, but wouldn’t want everyone to be part of a single-payer, government-run system. “I wouldn’t want one system,” he told BuzzFeed News. “I wouldn’t want that.”
We heard similar ambiguity when Vox conducted some focus groups with Hillary Clinton voters in suburban Washington, DC, last fall. Those voters, particularly the ones who currently had their own insurance through work, liked the idea of having a choice, having an option. They also liked the sound of Medicare-for-all, but a top-to-bottom overhaul of the American health care system made them nervous.
“To me, [single-payer] sounds like it’s somehow complete overhaul of everything, whereas Medicare-for-all sounds like warming people up to the idea using the structure that’s already in place to deliver that care,” Dennis, a 34-year-old Hillary Clinton voter in Bethesda, told us.
One of the things that made Democrats the most nervous about single payer is how political health care has become. They see how Trump has attacked Obamacare, and they see future Republican administrations meddling with single-payer health care as a real possibility. That could be a sticking point for some Democratic voters, especially those who are better off and already get good insurance through work.
Medicare-for-all is uniting Democrats for now — but it could divide them later
That explains why there’s this fledgling competition over what Medicare-for-all is really describing.
The best example might be the health care plan from the Center of American Progress, which is, tellingly, called “Medicare Extra For All.” It’s a seriously ambitious plan, one that would achieve universal coverage through a combination of government plans and private insurance, while preserving employer-based insurance for those who want it. But it is not single payer. And it is notably produced by an organization closely aligned with the Democratic establishment.
“To the extent there will be moments where we have to bring clarity to what Medicare-for-all means for us on the progressive side of the house, compared to other people who want to dance around the issue, we will do that,” Nina Turner, who leads the Sanders-affiliated Our Revolution, told me. “For us, at Our Revolution, it is Medicare for all, the whole thing, for everybody in this country.”
The scars from the Obamacare reveal themselves in this debate. For all the health care law has achieved, it also showed the limits of incrementalism. Even Medicaid expansion, the closest thing the law had to a single-payer pilot, was undermined by the Supreme Court by allowing Republican-led states to refuse it. The Obamacare insurance markets have been susceptible to sabotage from Republicans in Congress and the Trump administration.
Yes, the uninsured rate has reached historic lows under Obamacare, but 10 percent of Americans still lack coverage. Democrats will be faced again, at some point, with a choice between a more incremental approach, like the Medicare public options introduced by some Democrats in Congress, or a sweeping overhaul like single-payer. They can put it off for a while and campaign, as Green suggests, on whatever Medicare-for-all means to voters. But eventually that debate will need to be had.
Its outcome is far from certain. Eastman, one of Medicare-for-all’s most notable champions so far in 2018, described the dilemma perfectly.
She unambiguously supports single-payer Medicare-for-all. But “with the current Congress, with the current president, is that feasible?” she said. “I think you have to be practical about what’s happening in our country.”
Yet even if she recognizes the political realities of the moment, she wants Democrats to be bolder in their agenda.
“We have to stop backing off from this issue,” Eastman said. “That’s one of the problems with the ACA. It didn’t go far enough.”
How Kennedy’s SCOTUS Replacement Could Open the Door to Medicaid Cuts
Axios’ Caitlin Owens says the next Supreme Court justice could give states more power to cut Medicaid. The legal issue in question is whether private health care providers can sue over Medicaid payment rates. The Supreme Court ruled in 1990 that they could, and Anthony Kennedy dissented in that case — but took less of a hard-line stance than other conservatives. He “was willing to leave the courthouse doors open in Medicaid cases, whereas the conservative majority is willing to shut it – I mean, really slam it,” Sara Rosenbaum, a George Washington University law professor, told Axios.
Kennedy’s replacement could provide a fifth vote to prevent private providers from suing, giving states plenty of leeway to make cuts to their Medicaid programs without the threat of legal action.
Owens notes that Kansas and Louisiana have asked the Supreme Court to consider whether they can exclude Planned Parenthood from their Medicaid programs, and whether the group can challenge that exclusion.
More Americans Paid for ACA Plans This Year — and More Are Getting Priced Out
President Trump has declared that Obamacare is finished, dead, gone, essentially repealed. And yet, despite the administration’s efforts to undermine the law’s marketplaces, the number of Americans who enrolled in and started paying for Affordable Care Act plans grew slightly this year, according to reports released Monday by the Centers for Medicare and Medicaid Services (CMS).
At the same time, rising premiums are taking a toll, forcing many middle-income Americans — individuals making more than about $48,000 a year, or families of four making more than about $100,000 — to drop coverage. “Taken together, these reports show that state markets are increasingly failing to cover people who do not qualify for federal subsidies even as the Exchanges remain relatively stable,” CMS said.
Here’s a look at what the new reports show:
* While the total number of people who picked a plan for 2018 fell, the number of people who paid for coverage rose from 10.3 million in February 2017 to 10.6 million this past February, an increase of about 3 percent. “The increase is striking because it happened even though federal health officials last year slashed ACA funding to grass-roots groups that help consumers sign up for coverage, cut advertising and other outreach activities by 90 percent, and shortened the enrollment period by half,” writes Amy Goldstein at The Washington Post.
* CMS argued that, based on historical trends, a “significant number” of people will wind up dropping coverage during the year even after making their initial payments. Of the 10.3 million who paid for their plans as of March 15, 2017, only 8.9 million were still in those plans by the end of the year. “This is likely caused by consumers struggling to pay premiums as costs continue to increase,” the CMS report said.
* A larger share of enrollees has been getting federal subsidies. In 2014, the first year Affordable Care Act plans became available, 55 percent of those enrolled in individual market plans on or off the new Obamacare exchanges got financial help, according to Bloomberg. Last year, 62 percent did. In all, more than 8 million people got subsidies last year, while 5 million bought individual plans without financial help. “When premiums rise a lot, a lot more people become eligible for subsidies,” Matthew Fiedler, a fellow at the U.S.C.-Brookings Schaeffer Initiative for Health Policy, told The New York Times.
* As insurance prices rose by an average of 21 percent last year, signups among people who did not qualify for subsidies fell by 1.3 million — a drop of 20 percent compared with 2016. Subsidized enrollees fell by just 3 percent. “These reports show that the high-price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage,” CMS Administrator Seema Verma said in a statement. Trump administration policies may have played a part in the decline, too, and some people may have stopped buying their own insurance because they found jobs with employer coverage. “But it’s reasonable to think that most of the attrition can be attributed to the spike in prices, as the Trump administration concludes,” writes Margot Sanger-Katz of The New York Times.
What it all means: “The individual health insurance market under the ACA is financially sustainable as subsidies rise to match premium increases,” Larry Levitt of the Kaiser Family Foundation tweeted. “However, the lack of affordable insurance for middle-class people ineligible for subsidies does not seem politically sustainable.”
Where is Dr. King now? A Civility Emergency
As the well-known, dramatic story unfolds, “Humpty Dumpty sat on the wall, Humpty Dumpty had a great fall. All the king’s horses, and all the king’s men, couldn’t put Humpty Dumpty together again.” Coincidentally, this nursery rhyme has me thinking about an important leadership issue.
During this Independence Day season, I’m concerned that our freedom is being threatened. Now is the time for honorable patriots to speak up and do our part on this issue. We must take a stand for civility in our culture, and it’s a basic responsibility as fellow colleagues and citizens.
What is Civility and why is it important?
The word “civil” ties back to the Latin word for citizen, and the core meaning is the idea of people living together as a society under a government. The other well-known and related definition of the word civil is being courteous, respectful and considerate of others. To have and maintain freedom requires a degree of civility and tolerance for each other.
Just over fifty years ago Dr. Martin Luther King set the standard for civility when debating highly contested issues. Out of that era, our society learned a lot about respectful tolerance for others—it has been a foundational ethos over the past 30 years in the issues of race, gender, and religion, and it’s made us a better nation because of it. We had our differences in the past, but there was a general attitude of civility in debating them.
Today though, the tragic change is tolerance for being intolerant of others who have different ideas and views.
“When people reach a point of hate for each other because they have different perspectives, then you have a serious problem.”
Emotions are Contagious
From my past work in human behavior and performance, I know that emotions are contagious. Positive emotions give positive energy and make it easy to live and work together. Negative emotions bring negative energy and make it difficult to work together. We all know this principle from time spent with our work teams as well as relationships with family and friends. And the same thing applies to our culture.
Now we’re seeing intolerant and rude conversation on a mass scale. Some media outlets and politicians ignore the boundaries of civility, aggressively promoting disrespectful personal attacks on others who don’t share their views on politics or social issues. And social media has provided a layer of protection, allowing individuals to lash out in vicious ways at people they don’t even know. These actions aren’t illegal, but they are certainly anti-social and attack the civility needed to maintain a free society where we can live and work together.
Another Civil War?
A recent Rasmussen Poll showed that “thirty-one percent (31%) of U.S. voters say it’s ‘Likely’ that the United States will experience a second civil war sometime in the next five years, with 11 percent saying it’s ‘Very Likely.’[i]” This poll seems to confirm what I’m feeling—that we’re crashing over the boundaries needed in a civil society.
Underneath this breakdown in civility is the subtle mindset that “the ends justify the means”.
This is the bone-chilling Communist manifesto that we experienced in the POW camps, so I’m highly sensitive to this type of attack on freedom and independence. This abandonment of truth and civility can happen in our American culture, a business boardroom, a dysfunctional family relationship, or a dispute with a neighbor. No one can escape it, but we have an opportunity to do our part in arresting it.
What can we do?
If you’re agreeing with this article, then you’re part of the tribe that has decided to live and lead with honor! Regardless of your personal and professional perspectives or your allegiance to your like-minded group of people, you know that the true essence of influence and courage is taking a stand in a civil way regardless if that civility is returned in kind. For more on this challenge, see my coaching video this month and hear my personal story.
Here are four things that we can do –
- Guard your own character first. Avoid using uncivil tactics to advance your arguments.
- Be direct and honest, but keep strong boundaries on your words and actions. Set an example of someone who can disagree politely and factually with those with whom you disagree.
- Speak up when you experience the intolerance of others, those who resort to negative name-calling that is hateful and viscous. Consider how we can respectfully not tolerate those who use incivility as a weapon to advance their ideology.
- Get a free copy of the Honor Code and share it with others. Pay special attention to Articles 2, 6, and 7.
If Humpty Dumpty takes a fall, it will be very difficult to put him back together again. Take a stand for our freedom and independence, stand and advocate for civility…in a civil way.
Cartoon – The Warm Glow of Unconditional Love
HENRY KOTULA 