Democrats Have No Safe Options On Health Care

Democrats Have No Safe Options On Health Care

Even though most of the candidates have committed to some form of universal health care, the Democratic primary is turning into a debate about the future of the country’s health care system. Presidential hopefuls have proposed policies ranging from an ambitious four-year plan to transform Medicare into a universal single-payer system, in which the government pays for everyone’s health care and private insurance plans are effectively eliminated, to a more modest scheme that would leave the existing health care system intact but create a government-administered public insurance plan people could choose to purchase. But some of the candidates have been light on policy specifics, so it’s likely that health care will be a big topic at the debates and beyond.

In the abstract, focusing on health care makes a lot of political sense for Democrats. It was a top issue among Democratic voters in the 2018 midterms, and the Trump administration recently renewed its efforts to strike down the Affordable Care Act in the courts, which means the law could be hanging in the balance throughout the primaries and into the general election. A recent ABC News/Washington Post poll also found that Americans, by a 17-point margin, say that President Trump’s handling of health care makes them more likely to oppose him than to support him in 2020. By a similar margin, an Associated Press/NORC poll found that Americans trust Democrats more than Republicans on health care.

All of this means that Democrats are heading into the 2020 election cycle with a serious edge on an issue that has the potential to mobilize their base. But if the candidates pitch big, sweeping changes to the health care system without addressing voters’ concerns about cost and access, that advantage won’t necessarily hold up. And trying to sell Americans on a completely new system carries risks, even in the primaries.

Why do people care about health care so much?

First, it’s important to understand how health care has morphed over the past decade from just another issue to one of the issues voters care most about. In the 2018 exit polls, 41 percent of voters said health care was the most important issue facing the country, up from 25 percent in 2014 and 18 percent in 2012. (It wasn’t asked about in 2016.) And although Democrats are more likely to prioritize health care than Republicans, a Pew Research Center poll from January found that a majority of Republicans say health care costs should be a top priority for Congress and the president.

The reason? Health care is becoming more of a financial burden, according to Mollyann Brodie, executive director for public opinion and survey research at the Kaiser Family Foundation. Specifically, Americans’ out-of-pocket health care costs have risen significantly over the past decade, even for workers who get insurance through their jobs. In an economy that by many measures is doing well, health care — rather than something like taxes — is becoming one of voters’ most important pocketbook issues, she said. “If you’re worried about whether you or your loved ones can afford your next health care bill, that’s really a matter of life or death, so you can understand why this issue is moving to center stage politically.”

And Americans are increasingly likely to say that the government has an important role to play in ensuring access to health care. In November, Gallup found that 57 percent of Americans said they think it’s the federal government’s responsibility to ensure that everyone has health care coverage, up from a low of 42 percent in 2013. Support for the Affordable Care Act rose over the same period, too. But, notably, support for government intervention in the health care system was even higher before President Obama was elected and the ACA passed — in 2006, 69 percent of Americans thought the government should guarantee health care coverage.

While support for government involvement in health care is rebounding, it’s not clear how much change voters are really asking for. “The average American is first and foremost concerned about the financial problems facing their family,” said Robert Blendon, a professor of health policy and political analysis at Harvard. “They’re less worried about system-level concerns like health care spending and inequality. They want their existing coverage to be better and more affordable.”

What do voters want politicians to do?

Americans aren’t opposed to the idea of government-run health care, but there’s not a lot of consensus on what that would mean. For example, a recent Kaiser Family Foundation poll found that a majority (56 percent) of Americans favor a national “Medicare for All” plan. But according to a March Morning Consult poll, Americans are more likely to favor a plan that offers some kind of public option — a government-sponsored health insurance plan available in addition to existing private plans — over a system where everyone is enrolled in the same plan.

But this apparent contradiction makes sense, according to Brodie, because Americans are risk-averse when it comes to health care, and the switch to single-payer would affect far more people than the ACA did. Tens of millions of previously uninsured people received coverage under the ACA, but that number would be dwarfed by the 156 million people who get their insurance through their employers and could see their coverage change if the country switched to a single-payer plan. “Even if the current system isn’t working, transitions are scary,” Brodie said. “And people aren’t necessarily aware of what a national plan really means. When you start telling people that there might not be any more private insurance companies, that’s actually not a popular position.” For example, a January Kaiser Family Foundation poll found that support for a national Medicare for All plan dropped significantly when respondents were told it would mean eliminating private insurance companies.

And when asked what health care policies they want Congress to prioritize, Americans don’t list Medicare for All first. Instead, according to a recent Kaiser Family Foundation poll, they want Congress to pass targeted measures that would lower prescription drug costs, continue the ACA’s protections for preexisting conditions and protect people from surprise medical bills. Only 31 percent of Americans say that implementing Medicare for All should be a top priority for Congress, compared to 68 percent who want lowering drug prices to be a top priority. Moreover, prioritizing Medicare for All is politically polarizing: Only 14 percent of Republicans support putting that kind of plan at the top of the to-do list, compared to 47 percent of Democrats.

Some health care issues get only one-sided support

Share of Republicans and Democrats who say each issue should be a top priority for Congress, and the difference between the parties

Dem. Rep. Diff.
Making sure the ACA’s preexisting condition protections continue 82% 47% D+35
Implementing a national Medicare for All plan 47 14 D+33
Expanding government financial help for those who buy their own insurance coverage on the ACA marketplace to include more people 36 18 D+18
Lowering prescription drug costs for as many Americans as possible 77 66 D+11
Protecting people from surprise high out-of-network medical bills 55 45 D+10
Repealing and replacing the ACA 16 52 R+36

Source: Kaiser Family Foundation

However, smaller policy steps like lowering prescription drug costs and protecting people from surprise medical bills get more bipartisan support. Overall, Americans seem to be more concerned with fixing the current health care system than creating a sweeping new replacement — even if that replacement could address the issues they most want fixed in the current system.

What does this mean for the Democrats?

The complexity of Americans’ views on health care doesn’t change the fact that Democrats have a big advantage over Republicans on this issue, but it does mean that the individual candidates are in a tough spot because there’s no obvious unifying message they can adopt for the primary. And embracing a single-payer plan now could hand the GOP a weapon for the general election, allowing Republicans to frame the health care discussion around the Democrats’ controversial plan while glossing over Trump’s efforts to dismantle the ACA.

“The safest bet for a Democrat in the general election is to emphasize Trump’s track record on health care and say you’re going to make the ACA work,” Blendon said. The problem is that while that kind of argument might appeal to moderates, it’s likely to fall flat among a significant sector of the Democratic base that supports prioritizing a national Medicare for All plan over improving and protecting the ACA.

Democrats arguably still have an opening to make a case for a more ambitious health care overhaul, since voters still have relatively little information about what something like Medicare for All means. “It’s fine to support single-payer if you think that’s where the country needs to go, but you can’t just lean on principles like fairness or equality when you’re selling it,” said David Cutler, an economist at Harvard who advised Obama’s campaign on health care strategy. “You also have to tell voters, very specifically, what you are going to do to lower their costs and improve their coverage next year — not in 10 years.”

Even though Americans mostly prefer Democrats’ health care positions to the GOP’s, Democrats still risk alienating voters if they emphasize bumper-sticker slogans over concrete strategies for reducing the financial burden of health care. This is particularly important because their base of support for a single-payer system may be shallower than it appears, even within the party — especially when it comes to getting rid of private insurance. Big changes to the status quo are always politically challenging, but they may be especially risky when many Americans are concerned about losing the protections they already have.




Coping with Serious Illness in America

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Relying on Family and Friends

The luckiest among us have family and friends to lean on when times get tough. For those who develop a serious illness — an often painful and tumultuous experience — family and friends offer crucial emotional support and help with day-to-day activities. A recent survey of the sickest adults in America, conducted by the Harvard T. H. Chan School of Public Health, the New York Times, and the Commonwealth Fund, found that seriously ill adults also rely on their family and friends to organize their health care, helping them navigate an often complex, confusing, and inefficient system.

Focus groups and in-depth interviews conducted by the Commonwealth Fund since 2016 revealed that while taking care of a seriously ill family member or friend can bring meaning and satisfaction to caregivers, it also can become a complex and serious responsibility that burdens them.

Below we describe the many functions caregivers — defined as family and friends who provide care to the seriously ill — serve, as well as the financial, physical, and emotional challenges they face. We offer policy solutions, such as financial protections, employment flexibility, and training to prepare an “invisible workforce” for this deeply meaningful but sometimes overwhelming role.

Any one of us could find ourselves in the role of caregiver if we haven’t already. And our country and economy are likely to benefit when we help ensure caregivers are able to maintain their mental and physical health and stay in the workforce.

Learn more about the Health Care in America: The Experience of People with Serious Illness survey, including methodology and additional findings.

Many Caregivers Say They “Do Everything” for a Family Member or Friend with Serious Illness

Approximately 40 million Americans provide 37 billion hours of care and help each year to family members and friends. Most of the people with serious illness we surveyed (86%) reported that in recent years family and friends helped them deal with their medical or health condition at home.

Illness can make the simple activities of daily living, like cooking, cleaning, and bathing, nearly impossible, especially without assistance. Caregivers reported that helping with these routine tasks can become a huge commitment, and that the demand for care can escalate unexpectedly. “It started out as doing his laundry, getting groceries, but [my uncle’s] problems continued to get worse,” one caregiver explained. “There was really no other family in the area and now basically I do everything for him. I take him to his appointments. I cook his meals. When I leave him it almost feels like I’m leaving a child alone. It’s very scary.”

Even when a nurse or aide provides in-home help to the sick family member or friend, caregivers still need to organize the logistics of care, from scheduling doctors’ visits to taking time off work to provide transportation to the appointments and participate in the visits. Among people with serious illness we surveyed, more than half (55%) reported bringing a family member or friend to every medical appointment they had in recent years.

Our survey respondents also reported that they often relied on their family or friends who were health professionals (34%) for health care advice. These caregivers take on a number of important responsibilities for family members and friends with serious illness, such as helping to find qualified doctors, talking directly to the supervising clinician, and arranging appointments.

The Benefits and Tolls of Caregiving

People who care for a seriously ill family member or friend can benefit psychologically, emotionally, and socially from the experience. Previous studies have found caregiving increases self-confidence, makes caregivers feel closer to their ill family member or friend, and gives them the peace of mind that their family member or friend is well cared for. A daughter who cared for her mother with cancer described the fulfillment it brought her: “It meant a lot that I was able to be there for the person that was always there for me — who raised me and sacrificed for me.”

Despite the fulfillment caregiving can bring, it also can be incredibly burdensome and disruptive. The seriously ill adults we surveyed worry about the challenges their caregivers face. One seriously ill adult we spoke with said the following about her children: “Not only for my sake, but for the sake of my kids and my grandkids, I hope they are able to enjoy their later years and not worry about having to take care of me. I know they’d be glad to do it, but it has an impact on their lives, both short and long term.”

One-third (36%) of the seriously ill we surveyed reported that caregiving created problems for their family member or friend. These include emotional, physical, and financial strains.

Emotional strain

About one in three (31%) seriously ill adults in our survey reported their caregivers experienced emotional stress from caring for them. This is consistent with other studies that find caregivers experience significantly more stress than noncaregivers and have mental health issues like depression at twice the national rate. Caregivers who lack support from friends and family themselves are particularly affected by mental health issues and emotional strain.

Physical health issues

A quarter (25%) of the seriously ill adults we surveyed reported that their family or friend caregiver experienced physical strain from having to bathe, dress, and even lift them, to name a few issues. Other studies have shown just how powerful the physical toll of caregiving can be. Caregivers, compared to noncaregivers, are twice as likely to report chronic conditions like heart disease or diabetes, are more likely to view their health as fair or poor, and are even more likely to die. These physical consequences seem to be in part because of caregivers having limited time and resources to spend on their own health. They also may engage in unhealthy behaviors like drinking, eating poorly, and postponing their own doctors’ visits.

Financial problems

Nearly one in four (23%) seriously ill adults reported their caregiver experienced financial problems because of caregiving. Moreover, more than half (57%) of the seriously ill adults we surveyed said the costs of their medical care were a direct burden to their family. As seriously ill adults themselves face financial strain because of their condition, family members and friends may be left to pick up unpaid medical bills. Beyond paying directly for medical care, a study by AARP found that family caregivers spend on average close to $7,000 a year taking care of their family member, or about 20 percent of their annual income.

Employment disruption

Compounding the financial burden, caregiving can get in the way of work; 15 percent of the seriously ill we surveyed said their caregivers lost or had to change jobs because of their caregiving responsibilities.recent study found that nearly half of working caregivers said caregiving interfered with their job, and another 40 percent of those who were not working at the time of the study had quit their jobs or retired early because of caregiving. As one caregiver from our focus groups said, “My mother with Alzheimer’s lives with me. I manage all her affairs. I pretty much shut my life down to stop working and take care of her.” This need to drop out of the workforce is particularly concerning because the primary protection for working caregivers, the federal Family and Medical Leave Act (FMLA), offers only three months of unpaid leave. Moreover, it means the U.S. has fewer productive workers than it would if services were in place to support caregivers.

Support for “The Invisible Workforce”

There are several ways in which we as a nation could support this “invisible workforce” of caregivers — a group unseen, yet critical to the provision of care.

  • Education, training, and mental health support.Education and training on effective caregiving could help to improve both caregiver and patient outcomes. A recent study found that reviewing how to take care of their family member or friend before discharge from an inpatient hospital stay lowered the cost of postdischarge care and reduced readmissions. In addition, mental health support from behavioral health providers and others could offset the emotional and physical challenges caregivers experience. For example, a managed care plan in New Jersey, Amerigroup, hosts caregiver events where they provide educational workshops on illnesses and offer relaxation exercises to help caregivers cope.
  • Redesign health care for the seriously ill to make it less burdensome for patients and caregivers. Expanding the availability and affordability of respite care — which gives caregivers a temporary break — along with home care services, transportation, and care coordinators, would mean less responsibility for family and friends. AmeriHealth Caritas, for example, covers additional respite care beyond the state minimum to improve quality of life for enrollees and tackle caregiver burnout.
  • Financial support. Policies requiring paid leave for those working and taking care of sick family could protect them from some financial consequences and help keep them in the workforce longer term. In addition, federal and state policymakers could offer tax benefits, provide direct compensation, or allow family and friend caregivers to claim Social Security benefits for the time they spend caring for the seriously ill to offset financial costs. Lastly, payers can directly compensate caregivers for their time. For example, Medicaid long-term-care plans offer payment to caregivers for direct care, but the specific benefits and criteria vary from state to state. Paying informal caregivers could even save the health care system money long term by preventing more costly care later on.

Caregiving in America is not easy for the friends and family who provide this undervalued, unpaid, and even unrecognized service for both the person with serious illness and our society. To keep family and friend caregivers healthy and in the workforce, health systems, payers, and policymakers could expand training, increase insurance coverage for home-based services, and implement policies to financially protect caregivers.



Health Care in America – The Experience of People with Serious Illness

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Listening to People with Serious Illness

These are just a few of the many voices of people with serious illness. They express the bewilderment and the loss of control. They convey fear that the system is indifferent to their needs and that the cost of care is beyond their reach. They reflect the joy of feeling well enough to get back to the familiar parts of life.

Most Americans expect the health care system will deliver effective treatment and support them through trying times when they get sick. But in reality, health care in America sometimes hurts even as it helps. Appointments can be difficult to get. Clinics and emergency rooms are often overcrowded. Doctors’ recommendations can be confusing and difficult to follow. And when the bills arrive, the costs can be unexpected and devastating. More than 40 million adults in the United States experienced serious illness in the past three years. More than 41 million provided unpaid care to elderly adults during the past year.

Health Care in America: The Experience of People with Serious Illness, a project of the Harvard T.H. Chan School of Public Health, the New York Times, and the Commonwealth Fund, is examining the experiences of Americans with serious illness — the sickest of the sick — and those who help care for them. Our goal is to understand whether our health care system is doing all it can do not just to treat illness but to help people cope with illness. Where is the system failing to meet people’s needs? How is it adding to already heavy burdens? Can the most seriously ill Americans afford the care our health system delivers?

To help answer these and other questions, we surveyed nearly 1,500 Americans with serious illness and the friends or family members caring for them. We considered someone to have serious illness if, within the past three years, they had two or more hospital stays and visits with three or more doctors. Below we discuss what we found. We then point to opportunities to help ensure that American health care not only saves people but also supports them in their time of need.

Serious Illness: A Life-Altering Journey

People going through serious illness often experience profound loss: loss of control, loss of independence, loss of time, and the loss of capabilities that most of us take for granted. The physical, emotional, and financial toll can be life-altering. It can mean an end to the activities that give life pleasure; growing isolation from friends, family, and familiar places; and an inability to work or support others. And there is the worry of being a burden on family and friends.

People with serious illness experience distress over and above the physical symptoms of their specific condition. And our new survey reveals that many are distressed. Sixty-two percent feel anxious, confused, or helpless at some point. Nearly half have emotional or psychological problems. Social isolation, a known risk factor for worse health outcomes, is common, with one-third of respondents reporting feeling left out, lacking in companionship, or isolated from others.

Many people with serious illness want to continue working or continue to provide care for family and friends who need their help, but they face high hurdles. Nearly three of four have had problems related to work or their ability to care for others (Appendix 1). Half reported being unable to do their job as well as they could before. Twenty-nine percent lost a job or had to change jobs. Half reported wanting to work but being unable to do so.

Our Health Care System Often Adds to the Burden of Illness

It’s fair to say that several consequences of serious illness — the distress, isolation, confusion, and lost earnings — are simply part of being sick. In some cases, they are probably inevitable. But being sick in America also means carrying some burdens that our health care system foists upon us.

Americans have high expectations for their health care. Most believe that when serious illness strikes, their health professionals will be fully prepared to make a diagnosis and provide appropriate treatment. This belief is not wholly unwarranted, of course. News stories brim with pioneering medical advances. For people with what were once fatal and untreatable diseases, there are now cures. Once harrowing chemotherapy regimens have been replaced by pills taken once a day. New technologies are improving the quality of life for many people with serious disabilities.

A health care system that promises so much would seem capable of minimizing the burdens of illness and care, of helping people cope. But for too many, American health care does the opposite: it places unexpected and unnecessary burdens on the sick. People struggle to obtain effective treatments and services. Pervasive fragmentation and lack of coordination across the health system make obtaining services heavy labor for people with advanced illnesses or frailty.

How common are such problems for this vulnerable group? In our survey, six of 10 people with serious illness reported at least one problem receiving care (Appendix 2). The difficulties people reported are symptomatic of the confusing patchwork that is health care in the United States. Nearly a third of those with serious illness spoke of trouble understanding what their health insurance covered. Twenty-nine percent reported being sent for duplicate tests or diagnostic procedures by different doctors, nurses, or other health care workers. Twenty-three percent of respondents said they experienced a problem with conflicting recommendations from the health professionals that saw them. One of five had difficulty understanding a doctor’s bill — a confusion not just about the costs of care but about what services were provided.

Unnecessary tests and procedures are not only redundant and costly. They carry their own risks to health. Safety in health care is, in fact, an ongoing challenge, especially for patients requiring complex care plans. Nearly one of four adults in our survey reported a serious medical error in their care. We know from other studies that people with serious illness are especially prone to diagnostic errors, prescribing errors, and communication mishaps. Every doctor and many patients can recall missed abnormal lab results, failure to account for allergies, and lost information that led to terrible side effects, or even death.

Paying for Care: Teetering on the Edge of Financial Ruin

Health care can be extraordinarily expensive for anyone, but especially so for people with serious illness. Millions of Americans are ruined financially by the costs of their treatment. Although most survey respondents reported having insurance coverage, nearly one in 10 were uninsured. Even with coverage, many are not adequately protected from health care costs. More than half of people with serious illness in our survey (representing more than 21 million people) experienced one or more dire financial consequences related to their care (Appendix 3).

Apart from its sometimes lasting health consequences, serious illness also appears to cause long-term financial problems for many. More than one-third of survey respondents used up most or all of their savings. Nearly one-quarter were unable to pay for basic necessities like food, heat, or housing. Nearly a third were contacted by a collection agency for unpaid bills. And the financial consequences are not felt by patients alone. More than one in four survey respondents reported that the costs of care placed a major burden on their family.

What Can Be Done to Improve the Experience of the Seriously Ill?

The burdens described above are not an inevitable companion to serious illness. They are a consequence — at times inadvertent, but no less real — of how our health system operates today. But things could be different. It is fully within our means as a nation to improve the experience of the millions of Americans living with serious illness and the millions more who help care for them.

In fact, strategies for delivering a better health care experience — one that ensures comprehensive, holistic care while always respecting the dignity of the individual — already exist. They just need to be adopted on a much wider scale.

  1. Build the capacity to identify and manage the behavioral health needs of patients and their caregivers. Integrating behavioral health services into medical care requires more than simply improving communication among siloed professionals. Multidisciplinary care teams that include behaviorists, social workers, and patients working together can ease the sense of helplessness, the loss, and the social isolation that seriously ill people commonly experience.
  2. Assess and address social service needs. Our findings illustrate that the impact of serious illness extends well beyond the medical realm. Many people cannot work while dealing with a life-threatening condition. This means fewer resources at a time when expenses can increase dramatically. Access to and support for reliable transportation, supportive housing, nutritious meals, and other services are critical to helping the seriously ill maintain a level of well-being.

  3. Make it easier for patients, caregivers, and professionals to work in close coordination with one another. Patients want their clinicians and other providers to talk to each other — and they want in on the conversation, too. Providers can improve communication with each other, with patients, and with caregiving family members and friends by taking full advantage of advances in consumer-friendly digital tools like secure texting, email, telehealth, and social media platforms. Coordination could be further enhanced by care managers or community health workers who check in on patients and caregivers between appointments and connect them to needed services.
  4. Make care more affordable. Universal health insurance coverage is a fundamental protection against the cost of unexpected illness. It not only guards against the threat of financial ruin but minimizes the costs incurred by everyone else when sick people who are uninsured (or underinsured) show up in emergency rooms or hospitals, which by law must treat everyone in need of care. Guaranteed coverage of preexisting conditions is especially important to those who have experienced serious illness and would otherwise be denied coverage by insurers. Keeping out-of-pocket costs like copayments and coinsurance reasonable not only prevents bills from going unpaid but makes it easier for patients to stick with their preventive care regimen, avoid repeated emergency room visits and hospitalizations, and maintain progress in their treatment.


Americans have high expectations for their health system. They spend more than the citizens of any other country with the hope that the right care will be there for them when serious illness strikes. But along with the treatments and services that can improve life for the seriously ill come an unwanted and unnecessary set of physical, emotional, and financial burdens. These burdens result from the choices made by policymakers, practitioners, payers, and others. Listening to the voices of people with serious illness, reckoning with the human costs of our current system, and lifting the burdens that health care places on us when we become sick may be the most important work health care can undertake.


Repeal of Health Law Faces a New Hurdle: Older Americans

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Republican plans to repeal the Affordable Care Act have encountered a new obstacle: adamant opposition from many older Americans whose health insurance premiums would increase.

AARP and its allies are bombarding congressional offices with objections as two House committees plan to vote on the Republicans’ bill this week.

If the law is repealed, the groups say, people in their 50s and 60s could see premiums rise by $2,000 to $3,000 a year or more: increases of 20 percent to 25 percent or higher.

Under current rules, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. House Republican leaders would allow a ratio of five to one — or more, if states choose.

Insurers support the change, saying it would help them attract larger numbers of young customers.

The current rating restrictions, they say, have increased premiums for young adults, discouraging them from enrolling.

But the Republican proposal would “increase the financial burden of older Americans, making coverage significantly less affordable,” says a letter to Congress from the Leadership Council of Aging Organizations, a coalition of nonprofit groups that represent the interests of older Americans.

The letter was addressed to Representative Greg Walden, Republican of Oregon and the chairman of the Energy and Commerce Committee, one of two House panels planning to vote this week on a bill that would roll back major provisions of President Barack Obama’s signature domestic accomplishment.

David M. Certner, the legislative policy director of AARP, said the proposal would have “a severe impact on Americans age 50 to 64 who have not yet become eligible for Medicare.”

At the same time, Mr. Certner said, the Republican proposal could reduce the financial assistance available to help people pay insurance premiums.

Republicans say their proposal would reduce insurance prices by stimulating competition and by allowing insurers to sell a leaner, less expensive package of benefits.