Tag Archives: Single Payer Health System

Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again

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 President Trump will scrap subsidies to health insurance companies that help pay out-of-pocket costs of low-income people, the White House said late Thursday. His plans were disclosed hours after the president ordered potentially sweeping changes in the nation’s insurance system, including sales of cheaper policies with fewer benefits and fewer protections for consumers.

The twin hits to the Affordable Care Act could unravel President Barack Obama’s signature domestic achievement, sending insurance premiums soaring and insurance companies fleeing from the health law’s online marketplaces. After Republicans failed to repeal the health law in Congress, Mr. Trump appears determined to dismantle it on his own.

Without the subsidies, insurance markets could quickly unravel. Insurers have said they will need much higher premiums and may pull out of the insurance exchanges created under the Affordable Care Act if the subsidies were cut off. Known as cost-sharing reduction payments, the subsidies were expected to total $9 billion in the coming year and nearly $100 billion in the coming decade.

“The government cannot lawfully make the cost-sharing reduction payments,” the White House said in a statement.

It concluded that “Congress needs to repeal and replace the disastrous Obamacare law and provide real relief to the American people.”

In a joint statement, the top Democrats in Congress, Senator Chuck Schumer of New York and Representative Nancy Pelosi of California, said Mr. Trump had “apparently decided to punish the American people for his inability to improve our health care system.”

“It is a spiteful act of vast, pointless sabotage leveled at working families and the middle class in every corner of America,” they said. “Make no mistake about it, Trump will try to blame the Affordable Care Act, but this will fall on his back and he will pay the price for it.”

Lawmakers from both parties have urged the president to continue the payments. Mr. Trump had raised the possibility of eliminating the subsidies at a White House meeting with Republican senators several months ago. At the time, one senator told him that the Republican Party would effectively “own health care” as a political issue if the president did so.

“Cutting health care subsidies will mean more uninsured in my district,” Representative Ileana Ros-Lehtinen, Republican of Florida, wrote on Twitter late Thursday. She added that Mr. Trump “promised more access, affordable coverage. This does opposite.”

But Speaker Paul D. Ryan, Republican of Wisconsin, praised Mr. Trump’s decision and said the Obama administration had usurped the authority of Congress by paying the subsidies. “Under our Constitution,” Mr. Ryan said, “the power of the purse belongs to Congress, not the executive branch.”

The future of the payments has been in doubt because of a lawsuit filed in 2014 by House Republicans, who said the Obama administration was paying the subsidies illegally. Judge Rosemary M. Collyer of the United States District Court in Washington agreed, finding that Congress had never appropriated money for the cost-sharing subsidies.

The Obama administration appealed the ruling. The Trump administration has continued the payments from month to month, even though Mr. Trump has made clear that he detests the payments and sees them as a bailout for insurance companies.

This summer, a group of states, including New York and California, was allowed to intervene in the court case over the subsidies. The New York attorney general, Eric T. Schneiderman, said on Thursday night that the coalition of states “stands ready to sue” if Mr. Trump cut off the subsidies.

What the administration has done to weaken the health law.

Mr. Trump’s decision to stop the subsidy payments puts pressure on Congress to provide money for them in a spending bill.

Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, and Senator Patty Murray of Washington, the senior Democrat on the panel, have been trying to work out a bipartisan deal that would continue the subsidy payments while making it easier for states to obtain waivers from some requirements of the Affordable Care Act. White House officials have sent mixed signals about whether Mr. Trump was open to such a deal.

The decision to end subsidies came on the heels of Mr. Trump’s executive order, which he signed earlier Thursday.

With an 1,100-word directive to federal agencies, the president laid the groundwork for an expanding array of health insurance products, mainly less comprehensive plans offered through associations of small employers and greater use of short-term medical coverage.

It was the first time since efforts to repeal the landmark health law collapsed in Congress that Mr. Trump has set forth his vision of how to remake the nation’s health care system using the powers of the executive branch. It immediately touched off a debate over whether the move would fatally destabilize the Affordable Care Act marketplaces or add welcome options to consumers complaining of high premiums and not enough choice.

Most of the changes will not occur until federal agencies write and adopt regulations implementing them. The process, which includes a period for public comments, could take months. That means the order will probably not affect insurance coverage next year, but could lead to major changes in 2019.

“With these actions,” Mr. Trump said at a White House ceremony, “we are moving toward lower costs and more options in the health care market, and taking crucial steps toward saving the American people from the nightmare of Obamacare.”

“This is going to be something that millions and millions of people will be signing up for,” the president predicted, “and they’re going to be very happy.”

But many patients, doctors, hospital executives and state insurance regulators were not so happy. They said the changes envisioned by Mr. Trump could raise costs for sick people, increase sales of bare-bones insurance and add uncertainty to wobbly health insurance markets.

Chris Hansen, the president of the lobbying arm of the American Cancer Society, said the order “could leave millions of cancer patients and survivors unable to access meaningful coverage.”

In a statement from six physician groups, including the American Academy of Family Physicians, the doctors predicted that “allowing insurers to sell narrow, low-cost health plans likely will cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options.”

While many health insurers remained silent about the executive order, some voiced concern that it could destabilize the market. The Trump proposal “would draw younger and healthier people away from the exchanges and drive additional plans out of the market,” warned Ceci Connolly, the chief executive of the Alliance of Community Health Plans.

Administration officials said they had not yet decided which federal and state rules would apply to the new products. Without changing the law, they said, they can rewrite federal regulations so that more health plans would be exempt from some of its requirements.

The Affordable Care Act has expanded private insurance to millions of people through the creation of marketplaces, also known as exchanges, where people can purchase plans, in many cases using government subsidies to offset the cost. It also required that plans offered on the exchanges include a specific set of benefits, including hospital care, maternity care and mental health services, and it prohibited insurers from denying coverage to people with pre-existing medical conditions.

The executive order’s quickest effect on the marketplaces would be the potential expansion of short-term plans, which are exempt from Affordable Care Act requirements. Many health policy experts worry that if large numbers of healthy people move into such plans, it would drive up premiums for those left in Affordable Care Act plans because the risk pool would have sicker people.

“If the short-term plans are able to siphon off the healthiest people, then the more highly regulated marketplaces may not be sustainable,” said Larry Levitt, a senior vice president for the Kaiser Family Foundation. “These plans follow no rules.”

Mr. Trump’s order would also eventually make it easier for small businesses to band together and buy insurance through entities known as association health plans, which could be created by business and professional groups. A White House official said these health plans “could potentially allow American employers to form groups across state lines” — a goal championed by Mr. Trump and many other Republicans — allowing more options and the formation of larger risk pools.

Association plans have a troubled history. Because the plans were not subject to state regulations that required insurers to have adequate financial resources, some became insolvent, leaving people with unpaid medical bills. Some insurers were accused of fraud, telling customers that the plans were more comprehensive than they were and leaving them uncovered when consumers became seriously ill.

The White House said that a broader interpretation of federal law — the Employee Retirement Income Security Act of 1974 — “could potentially allow employers in the same line of business anywhere in the country to join together to offer health care coverage to their employees.”

The order won applause from potential sponsors of association health plans, including the National Federation of Independent Business, the National Restaurant Association, the U.S. Chamber of Commerce and Associated Builders and Contractors, a trade group for the construction industry.

The White House released a document saying that some consumer protections would remain in place for association plans. “Employers participating in an association health plan cannot exclude any employee from joining the plan and cannot develop premiums based on health conditions” of individual employees, according to the document. But state officials pointed out that an association health plan can set different rates for different employers, so that a company with older, sicker workers might have to pay much more than a firm with young, healthy employees.

“Two employers in an association can be charged very different rates, based on the medical claims filed by their employees,” said Mike Kreidler, the state insurance commissioner in Washington.

Mr. Trump’s order followed the pattern of previous policy shifts that originated with similar directives to agencies to come up with new rules.

Within hours of his inauguration in January, he ordered federal agencies to find ways to waive or defer provisions of the Affordable Care Act that might burden consumers, insurers or health care providers. In May, he directed officials to help employers with religious objections to the federal mandate for insurance coverage of contraception.

Both of those orders were followed up with specific, substantive regulations that rolled back Mr. Obama’s policies.

In battles over the Affordable Care Act this year, Mr. Trump and Senate Republicans said they wanted to give state officials vast new power to regulate insurance because state officials were wiser than federal officials and better understood local needs. But under Thursday’s order, the federal government could pre-empt many state insurance rules, a prospect that alarms state insurance regulators.

Another part of Mr. Trump’s order indicates that he may wish to crack down on the consolidation of doctors, hospitals and other health care providers, a trend that critics say has driven up costs for consumers. Mr. Trump said that administration officials, working with the Federal Trade Commission, should report to him within 180 days on federal and state policies that limit competition and choice in the health care industry.

Socialized Medicine Has Won the Health Care Debate

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https://newrepublic.com/article/145067/socialized-medicine-won-health-care-debate

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“It’s coming down to a choice between Federalism vs Socialism,” Senator Lindsey Graham proclaimed on Twitter earlier this week. “I chose Federalism of #GrahamCassidy.” His tweet echoed his words at a press conference days earlier, where he framed his Affordable Care Act repeal bill as the only way “to stop a march toward socialism.”

It’s unclear if the Republican senator realized that he was cribbing from socialist revolutionary Rosa Luxemburg. In a pamphlet composed a century ago while in prison, Luxemburg wrote: “Bourgeois society stands at the crossroads, either transition to socialism or regression into barbarism.” Graham, presumably, didn’t mean to liken his bill to barbarism. But increasingly, those are the terms in which Americans view the health care debate—as a choice between socialism and regression. Republicans have used “socialized medicine” as a bogeyman—and they’ve steadily lost ground on the issue. Despite Graham’s attempts to portray the idea of caring for sick people regardless of their income level as a “nightmare” scenario, just 7 percent of those polled thought Graham-Cassidy would help them.

The repeated rebukes of attempts to undo Obamacare have shown that the average American is no longer moved by the threat of the “S-word.” If we are on a slippery slope toward socialized medicine, it appears that Americans are just fine with that. For the left, there’s a lot to learn from the successful battles against going backward on health care—lessons about how Trump-era politics can be used to push “socialist” policies that move Democrats, and the American public, forward in unexpected ways.

Introduced after the Bernie Sanders Medicare for all bill made its debut with 16 co-sponsors in the Senate, the Graham-Cassidy bill looked all the worse by comparison. Both bills arrived at the end of a summer of activism, a summer that has treated us repeatedly to the sight of people in wheelchairs carted out of the Senate chanting, “No cuts to Medicaid! Save our liberty!” The health care movement has been led by the people directly affected—people with disabilities, in many cases, along with veterans of the AIDS movement. They understood the power of spectacle, initiating those dramatic clashes at the Capitol. They also know better than anyone the inequalities baked into the existing system. Their fighting skills were honed fighting for decades against those who say, implicitly or explicitly, that they don’t deserve care.

Of course, politicians have long been disconnected from the American public on the issue of health care. But the movement to defend Obamacare has drawn into stark relief the difference between what people want and what politicians want to offer. Republicans like Graham banked on the attachment Americans have to the class system we like to pretend doesn’t exist. They played on the idea, honed through decades of dog-whistles, that government programs are always giveaways for the undeserving poor and people of color. As one law professor and conservative columnist complained on Twitter, “Years from now, when your child is denied a liver transplant bc of transplant diversity goals, you’ll be sorry you allowed single-payer.”

In the U.S., we tend to either deny the existence of class or treat it like a set of characteristics divorced from power relations. A Make America Great Again baseball cap, a taste for Budweiser and NASCAR—those, rather than income level or accumulated wealth, are the signifiers of class that we understand. Meritocracy is supposed to be the thing we have instead of class; you can hear it in the endless bipartisan odes to the ability to work hard and achieve anything—including, apparently, a liver transplant if necessary.

Barack Obama and Ben Carson are both heroes of the meritocratic tale, though with a different partisan inflection. Even Sanders falls victim to the meritocratic narrative at times, with his refrain that “No one who works 40 hours a week should be living in poverty.” The implication that comes with Sanders’s qualifier is that there are some people who may, in fact, deserve to be living in poverty. If class is just about some personal preferences rather than structures that maintain inequality, then it’s fine to maintain a healthcare system that treats only those who can afford it. After all, if they just worked harder, they’d have earned that liver.

Graham’s single most tone-deaf argument to sell his bill was drawing an analogy to welfare reform. Welfare reform, of course, was sold to the country by Reagan, Gingrich, and Bill Clinton through fearmongering about undeserving black mothersand “young bucks.” Graham’s rhetoric about the size of the Medicaid budget leaned hard on this analogy, hoping that Americans resented Medicaid as much as they were taught to resent welfare.

Like welfare reform, Graham-Cassidy would have turned Medicaid and the subsidies in the ACA into block grants for the states to manage as they see fit. But the problem with health insurance is that it is designed to be used. The goal of welfare reform was to kick people off of welfare; the goal of healthcare reform was theoretically to get more people onto health insurance plans. Welfare reform increased poverty; Graham and Cassidy didn’t want to admit their bill would do the same. The analogy failed, though it told us a lot about what Republicans think of the people who use Medicaid.

The ham-handed Republican attempts to dismantle the health care system—the “socialism” warnings, the appeals to the selfishness of privileged white folks—have only reinforced the public’s support for government taking care of its citizens. It was telling how, in Monday night’s televised debate between Graham and Cassidy and Senators Sanders and Amy Klobuchar, Graham fell right into a trap, unintentionally proving his opponents’ point about what Americans want. When Sanders asked, “Do you know what the most popular health insurance program in America is? It’s not the private insurance industry,” Graham jumped in like an overeager schoolchild: “It’s Medicare,” he said.

Both Republicans and Democrats have badly misunderstood what makes Obamacare unpopular. What people don’t like are the inequities that still prevail in our health care system, not the fact that “government is too involved.” When Vox’s Sarah Kliff visited Whitley County, Kentucky, to talk to Trump voters who benefited from the ACA, she heard complaints from those buying private insurance with their subsidies that their deductibles were still too high for them to access care. Others, not surprisingly, were angry that the very poor got Medicaid, while they had to pay monthly premiums for care they rarely used. But that anger hasn’t turned them against the program. Medicaid expansion—the “socialized” part of the ACA—remains wildly popular, with 84 percent of those polled by Kaiser Family Foundation saying it’s important to keep the expansion.

The ACA’s means-testing sets up a hierarchy of plans that at times seem calculated to fuel resentment of those getting “free stuff.” It also requires hours of work—I write from personal experience, as a freelancer who has attempted to explain repeatedly that my income varies from month to month and year to year—to prove to the system that you are not getting away with something you haven’t qualified for.

The ways that people have tried to patch the gaps that remain in Obamacare, through charities and crowdfunding, have also highlighted its inequities. As Helaine Olen recently wrote in The Atlantic, charities, too, are often means-testing applicants, while crowdfunding introduces a new kind of means-testing—“means-testing for empathy,” as writer Patrick Blanchfield told me recently. Most GoFundMe or YouCaring campaigns for medical bills don’t go viral; only around 10 percent of them met their stated goals. For those who have a big social media audience, or whose particularly compelling story takes off, crowdfunding might work. But the glut of such campaigns leaves people weighing story against story, deciding who is going to get their donations. It’s health care by popularity contest.

By focusing on the not-good poll numbers for Obamacare, politicians and pundits have missed the whole point: The law didn’t go too far for Americans to get behind. It didn’t go far enough. And while single-payer opponents continue to evoke rationed care, long lines and wait times, and other problems that supposedly plague England or Canada, the public seems well aware that the reality for many Americans is far worse. By their very complaints, the pundits and politicians continually highlight the inequality in the system; the complainers are those who can afford the kind of carethat comes with personal attention, privacy, shorter waits, and avoidance of rubbing elbows with undesirables.

To move forward, then, the single-payer movement should double down on what we learned through this fight: that expanding Medicaid made it harder, not easier, to claim that the program is a “giveaway” to undeserving poor. The willingness of people with disabilities to claim and hold the spotlight—as the New Republic’s Sarah Jones has written—has helped to challenge our preconceptions about who relies on Medicaid ,and to make politicians confront those who will not be served by a market-based program. And the willingness, finally, of politicians to fight publicly for single-payer—rather than mournfully shake their heads and say it will never happen—expands the range of policies that even establishment media is willing to discuss.

Most important, we have learned that the old fearmongering tropes about socialism are no longer enough to whip Republican votes for a major plank of their own platform. If anything, the successful fight should help progressives shed their fears of boldly advocating for what they know is right and working to change public sentiment without endlessly obsessing over potential political pitfalls.

It seems that barbarism, to Graham and his ilk, is the idea that they would lose their right to segregated, high-end care to some undeserving, poor person of color. To the rest of us, however, barbarism is a system that decides who deserves to live or die by the color of their skin, the money in their bank account, the hours that they work, or their ability to work at all. This is now an American consensus. And if socialism is the medicine our system needs, the country is ready to embrace it—even by name.

The Best Health Care System in the World: Which One Would You Pick?

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“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

  • Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine
  • Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

  • Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management
  • Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs
  • Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

A summary of our worldviews on health care is at bottom.

So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts’ selections will decide who advances). When we cite hard data, they come from the Commonwealth Fund’s International Country Comparison in 2017.

But enough talk. Let’s play.

Why Bernie Sanders’s plan for universal health care is only half right

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https://www.brookings.edu/blog/fixgov/2017/09/13/why-bernie-sanderss-plan-for-universal-health-care-is-only-half-right/?utm_campaign=Brookings%20Brief&utm_source=hs_email&utm_medium=email&utm_content=56298642

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Sen. Bernie Sanders plans to introduce his universal health care bill Wednesday; it is likely to serve as a litmus test for Democrats with presidential aspirations. The legislation is bold and simple, which makes it very appealing. A recent survey by the Pew Research Center found that 60 percent of Americans believe the federal government should ensure health coverage for all Americans.

But Sanders’s bill only gets it half right.

The part that’s right is that every American would automatically get health insurance. If that came to pass, the door would be open to lowering costs while eliminating the highly complex regulations needed to police our current system and the inequitable tax treatment that sustains it.

The part that Sanders gets wrong is that he would turn Medicare into a single-payer system for all, supplanting private insurers.

That approach has lots of problems, not least of which is an enormous price tag. Consider what happened in California earlier this year when the state legislature briefly considered a single-payer bill. An appropriations committee estimated it would cost $400 billion, over twice the state’s annual budget. Such complications make the Sanders bill — and other Medicare for all proposals — virtually impossible to enact.

People also forget that Medicare is a hidebound system. It took Congress more than 40 years to offer a prescription drug benefit, for example. Physicians are paid using an arcane system developed decades ago and that has now ballooned to more than 140,000 procedure codes, all of which is supervised (and gamed) by physicians themselves. Standard private sector cost-saving measures, like competitive bidding for routine services, are rarely used.

There is a better way — called universal catastrophic coverage — which borrows from both progressive and conservative playbooks. It would combine the federal guarantee of insurance for all with the cost-controlling benefits of insurers competing for that business.

From the consumer viewpoint, universal catastrophic coverage would look like this: All Americans not covered by Medicaid and Medicare would be placed in a single, massive risk pool. The government would assume the risk of insuring everyone, using a high-deductible policy that would guarantee that no one would be without care in the event of a health care crisis.

To keep the plan progressive and affordable for all, deductibles would be tied to income. Services that are very effective would be exempt from the deductible and fully covered. This includes many prevention services — like flu shots — but also medications for chronic disease, certain vaccines, and the like.

This would eliminate a host of problems in the current system: no more worries about preexisting conditions, no more losing insurance when changing jobs, no more mandated buy-in, and no more upward spiraling of premiums for those buying policies because healthy people are staying uninsured and not paying their share.

From the point of view of insurers, the new system would look like Medicare’s prescription drug plan, in which they compete for market share by offering different networks, deductibles, premiums, and supplemental coverage.

A version of universal catastrophic coverage that I devised with my colleague, Kip Hagopian, would cost the government about 15 percent less than the Affordable Care Act while insuring 115 million more people, according to a RAND study. Premiums would be about $3,000 annually, about 40 percent less than the ACA silver plans.

This approach borrows from liberal dreams for health care as a right, and from conservative conviction that market forces are the most efficient way to deliver health care and keep costs under control. That is why both sides can support it.

Being bold means asking for big changes. The current system of employer-based insurance would lose its tax-protected status, which currently costs the federal government $236 billion (about the same as the mortgage interest deduction, charitable deductions, and retirement benefit exclusions combined, according to the Tax Policy Center). Those savings would be used to underwrite the new system.

Vested interests will find many reasons to oppose change. But the bottom line is that we can cover everyone if we are smart about it.

The Single Payer Debate

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http://www.rollcall.com/news/politics/sanders-displays-political-clout-single-payer-movement?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters

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The seismic shift in support for Sen. Bernie Sanders’ plan to transform the U.S. health care system into a single-payer program indicates the reach the Vermont independent has within the Democratic Party.

At the same time that his onetime presidential foe Hillary Clinton is reminding people of the party’s devastating loss last fall, Sanders is trying to define its future. His bill to enroll every American in Medicare drew 16 co-sponsors, 16 more than when he first introduced similar legislation in 2013.

It has garnered support from possible 2020 Democratic presidential hopefuls — Sens. Cory Booker of New Jersey, Kamala Harris of California, Elizabeth Warren of Massachusetts and Kirsten Gillibrand of New York — as well as Sen. Tammy Baldwin of Wisconsin, an incumbent up for re-election next year in a state narrowly won by President Donald Trump.

It also provided a welcome talking point for Republicans who have long railed against government-run health care. Several GOP senators used Sanders’ legislation as a tool to warn voters of what could come if Republicans are unable to overhaul the health care system.

‘A political crisis’

During a bill introduction Wednesday that felt more like a campaign rally than the standard press conference, Sanders — flanked by co-sponsors — stuck to his standard script of bashing Republicans and special interest groups for doing nothing to address rising health care costs.

“The crisis we are discussing is not really about health care,” he told a crowded room of activists and supporters. “The crisis we are discussing today is a political crisis which speaks to the incredible power of the insurance companies, the drug companies and all those who make billions of dollars off of the current system.”

The politics of “Medicare for all” are divisive. And aside from a short comment about raising taxes across the board, Sanders has yet to outline a clear way to pay for such a system.

There is a divide within the Democratic Party on how to define such a system, and many Senate Democrats have yet to voice their support for Sanders’ plan, including vulnerable incumbents up for re-election such as Sen. Joe Manchin III of West Virginia.

Despite those differences, however, the expanding coalition of Democrats who now back such a proposal is a display of just how Sanders, who gave Clinton a serious challenge for the presidential nomination, continues to influence the national party.

“Sen. Sanders’ presidential campaign was a phenomenon that very few people saw coming. It uncovered a groundswell of progressive activation that the party now rightly wants to tap into as we head into 2018 and 2020,” Connecticut Democratic Sen. Christopher S. Murphy said. “I think that Democrats now feel a little freer to imagine some even bigger and bolder ideas.”

Asked whether the growing support for his legislation is indicative of his influence, Sanders hedged.

“Right now, we are focusing on what the bill is about,” he said. “We’ll talk about the politics of it later.”

A national message?

Several other Democratic senators supported the national party embracing more bold ideas — like Medicare for all — in the fallout from the 2016 election and tied that movement directly to the success of Sanders’ campaign.

“It’s an idea whose time has come. There’s a clear recognition that universal coverage has to be the goal,” Democratic Sen. Richard Blumenthal of Connecticut said. “These principles are now in the public mind, front and center, and that is due, in part, to the prominence that Bernie Sanders gave to them during the campaign.”

A Democratic aide echoed those thoughts and said the shift is indicative of a recognition that the party needs to be bolder and sharper in its proposals.

“I think there will be a lot of support for this bill,” the aide said. “It’ll make the clear contrast between the two parties on health care even more clear.”

While the Sanders proposal has gained more support among members of the Democratic conference, skeptics remain.

“The Sanders bill requires people to give up their insurance. It’s not an option that you buy in. It requires people to give up the insurance,” Sen. Claire McCaskill of Missouri said. “I’ve been down the road of requiring people to do things the government says on insurance and it is a road paved with big rocky boulders.”

Asked whether she correlates the growing support for Medicare for all to Sanders’ popularity among liberals, McCaskill — who is up for re-election in 2018 in a state Trump won easily — said she had not analyzed it from that perspective.

“I just think we’ve got to think this through and not make this some kind of political litmus test,” she told Roll Call.

While other Democratic lawmakers also said they hoped support for the Sanders bill would not be a political benchmark for the party, several openly said endorsing the concept would be crucial for any successful candidate.

“I have trouble seeing how a viable Democratic candidate does not support the idea of single-payer,” Blumenthal said. “This bill is going to drive the national message.”

Bernie-Care barrier?

Some Senate Republicans, who this summer failed in their attempt to repeal and replace the 2010 health care law, are making a last-ditch attempt to overhaul it.

Sens. Bill Cassidy of Louisiana, Lindsey Graham of South Carolina, Ron Johnson of Wisconsin and Dean Heller of Nevada are pushing legislation that would transform the health care system to essentially a large federal block grant to the states based on the size of their individual insurance pool.

Their message to the Republican conference was clear: It’s either our plan or Sanders’ proposal.

“If you want a single-payer health care system, this is your worst nightmare,” Graham said. “Bernie, this ends your dream of a single-payer health care system for America.”

Republican leadership echoed that message.

“We see what the alternative is and hopefully that’ll focus the mind,” Senate Majority Whip John Cornyn said. “Their party is clearly lurched to the left even further, and it’s made it hard for otherwise pretty pragmatic people, like Chuck Schumer, to do deals which he ordinarily would do with Republicans.”

But for Sanders, the failed attempt by the GOP to overhaul the current health care law only bolsters his case.

“To my Republican colleagues, please don’t lecture us on health care,” he said. “You, the Republican Party, have no credibility on the issue of health care.”

GOP Sees Offensive Opening on Health Care for 2018

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http://www.rollcall.com/news/politics/gop-medicare-for-all-strategy?utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters&utm_source=rollcallheadlines&utm_medium=email&utm_campaign=newsletters

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Republicans plan to tie all Democrats to “Medicare for all” proposals.

As more and more Democrats come out in favor of some form of “Medicare for all” legislation, Republican campaign strategists are salivating.

In much the same way the GOP has tried to tie all Democrats to House Minority Leader Nancy Pelosi in attack ads, they’re planning to tie all Democratic incumbents and challengers to different proposals from Vermont independent Bernie Sanders in the Senate and Michigan Rep. John Conyers Jr. in the House, regardless of whether they’ve personally embraced those policies.

“I’m thrilled,” said Corry Bliss, executive director of the Congressional Leadership Fund, the leadership-backed super PAC that plans to spend $100 million to help Republicans keep their House majority in 2018.

“I love their new policy so much that I’m thinking about taking the $50 or so million I was planning on spending on attacking Nancy Pelosi and putting a small portion toward explaining how single-payer hurts the American people,” Bliss said Tuesday.

That strategy isn’t much different from the GOP strategy of the past seven years, when the party has gone after Democrats on the 2010 health care law. But after months of their own health care legislative failures, Republicans think they finally have an offensive opening on health care again.

“It’s first time we’ve been in that position in a long time,” said one GOP campaign strategist, who acknowledged that this year’s health care debate revived the 2010 law.

Attacking all Democrats

The National Republican Congressional Committee was especially vocal on Wednesday, with a digital ad and a slew of press releases trying to pin Sanders’ proposal on Democratic incumbents and challengers.

“Studies reveal that single-payer would cost taxpayers a staggering $32 trillion over the next ten years,” the releases say, all pointing to the same study from the Urban Institute from May 2016.

“Sanders and Pelosi are leading their members down a path with nowhere to turn but left,” NRCC communications director Matt Gorman said in a statement.

In reality, Pelosi has shied away from Medicare for all proposals, trying instead to keep her caucus’ focus on improving the 2010 health care law. Her reticence toward the issue is a fact Republicans sometimes highlight to underscore its unpopularity — as in, “This is such a bad idea, Nancy Pelosi doesn’t even support it.”

But when it comes to messaging against the proposals, Republicans are happy to include Pelosi — a perpetual boogeyman — to help tie the issue around the neck of all Democrats.

California Rep. Scott Peters, a member of the moderate New Democrat Coalition and chairman of the group’s PAC, brushed aside the threats of those kinds of attacks.

“That won’t be a very effective campaign technique. People understand where we are,” he said, walking down the House steps Wednesday afternoon. Peters, an NRCC target in 2018, doesn’t support the Conyers legislation.

But with a majority of House Democrats signing onto it, and many 2020 hopefuls embracing the Sanders plan in the Senate, Republicans see it as nationalized party issue they can apply down ballot to all candidates.

“This is going to help frame the choice next year,” Bliss said. “It will be a huge issue in every single district that we spend in next year.“

One Republican admitted, though, it may be harder to message against a Democratic proposal that doesn’t stand a chance of becoming law anytime soon and doesn’t have a Democratic president behind it.

“I don’t think it will get to the same level as Obamacare did in the 2010 cycle,” the GOP strategist said. “You don’t have the same boogeyman in President Obama and Pelosi.”

Still, Republicans hope the issue will help them by pushing Democratic candidates to the left and sinking nominees in red districts or states won by President Donald Trump last fall.

In Wisconsin, where Trump eked out a win, Sen. Tammy Baldwin has come out in support of Sanders’ legislation. She’s the only senator up for re-election in a state the president won to have signed onto the Sanders’ proposal.

Trump has called for “insurance for everybody,” but Republicans say it’d be very easy to message against a Medicare for all plan to his voters.

“Here’s a socialist idea where everyone gets the same thing,” the GOP strategist said. “That doesn’t play.” It doesn’t fit with what she called the “you deserve more” narrative that Trump pushed to working-class voters during the campaign.

Keeping up the heat

Democrats aren’t backing away from their own offensive attacks on health care, trying to make the GOP-controlled Congress own their repeal-and-replace efforts.

That continued on Wednesday, with the introduction of the Senate Republicans’ latest effort at repealing the 2010 health care law.

“The 2018 election will be a referendum on the toxic GOP health care plan that spikes costs and strips coverage,” said David Bergstein, spokesman for the Democratic Senatorial Campaign Committee.

And they’re skeptical that this week’s attention on the Medicare for all legislation will take away from what a GOP-controlled Congress has been able to do — or not do — on health care this year.

“To have that be their golden ticket out of the nightmare they face right now seems just insane,” one Democratic operative said.

 

The Politics of Single Payer Healthcare

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https://www.axios.com/how-single-payer-helps-republicans-change-the-subject-2484804538.html?utm_campaign=KFF-2017-Drew-Axios-Sept14-single-payer&utm_medium=email&_hsenc=p2ANqtz–Q_Zmd1SqMI79AseTc1OIcHEN8DwUamYUmNIxGr2HLethhmoTOcQG43KssI13yVmZtpoP_AaEj9gRTHI4q68FAj7yloQ&_hsmi=56318621&utm_content=56318621&utm_source=hs_email&hsCtaTracking=18c76970-ffc0-4c0b-bb7a-ae1162b26233%7C7e107385-a85c-47b5-9c31-a303df175f96

 

Since the collapse of the GOP effort to repeal and replace the Affordable Care Act, single payer has gained new life on the left. Sen. Bernie Sanders released his “Medicare for all” plan yesterday, and a majority of House Democrats have signed on to another version proposed by Rep. John Conyers.

Data: Kaiser Family Foundation Polls; Note: 2008-09 is an average of 7 polls; Chart: Andrew Witherspoon / AxiosThe big picture: Politically, single payer — the idea of having the government pay for health care rather than private insurers — can help rally the left much like the prospect of repealing the ACA rallied the right. But it could also help Republicans, who own the problems in health care now, switch the target to the Democrats and their sweeping new health reform plan.

The pros for Democrats:

  • As the chart shows, single payer is popular among Democrats, with about two thirds in favor. But it has also gained popularity among independents in recent years, with over half supporting it. Republicans, not surprisingly, aren’t so crazy about it.
  • Single payer is a big idea many Democrats can rally around. It excites the base and party activists by establishing health care as a right, achieving universal coverage, and eliminating insurance companies. This analysis is about politics, but most advocates of single payer advance the idea because they believe in it, not as a political calculation.

The cons for Democrats:

  • They could lose a one-time opportunity to tar Republicans with the damage their ACA replacement plan would have done to millions of people, according to the multiple analyses that showed lost coverage and higher premiums for vulnerable people.
  • By campaigning on their own sweeping health reform plan, Democrats could give Republicans a fighting chance to change the subject.
  • More targeted policy ideas, such as Medicaid buy-in options for the ACA marketplaces and a Medicare buy-in for 50-64 year olds, could also be popular on the left and the center, while offering far smaller targets than a sweeping single-payer plan would.

Reality check: Single payer is popular, but polling today doesn’t tell us much about where the public will be if there is a national debate about actual single-payer legislation in the Congress. ACA repeal had the support of about half the public in Kaiser Family Foundation polling in late 2016 and early 2017, but fell to closer to 30 percent once there was an replacement plan under the microscope.

Support for single-payer falls by 10 to 20 percentage points when people are read common criticisms, such as that it will increase taxes or give the government too much control over health care. Arguments in favor, including that single payer will make health a basic right or reduce administrative costs, increase support by similar amounts.

We cannot simulate what will happen in a real debate, which depends on the actual details of the legislation and the power of the arguments made.

Be smart: This is more than just a health policy debate. It is also a proxy debate about the future of the Democratic Party. The party can swing left trying to build energy in the base, or it can move to the center, trying to capture the votes of many of the more conservative working people who voted for President Trump.

Don’t forget: Most Americans are far less focused on sweeping health policy ideas than they are on lowering their out-of-pocket costs. Health reformers – left, right, or center – who make the connection between their policy ideas and these pocketbook concerns may capture the most voters.

Incentives Are All Wrong for Single-Payer Health Care

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https://www.bloomberg.com/view/articles/2017-09-12/incentives-are-all-wrong-for-single-payer-health-care

Americans won’t give up their private insurance unless the government option is better. And that won’t be cheap.

The conventional wisdom these days is that the major Democratic presidential candidates for 2020 will end up endorsing some version of single-payer health care. Senator Bernie Sanders is expected to introduce his Medicare for All bill this week, with a considerable number of co-sponsors. This political posturing, however, is far from a practical proposal.

There’s an obvious problem with moving Americans to a single-payer system: Most people with private health insurance are pretty happy with their current arrangements. They are not looking to trade in that coverage for a new government program of uncertain quality, along with unknown higher taxes. When President Barack Obama was selling the Affordable Care Act, he promised Americans that they could keep their health insurance if they wanted to. When this didn’t turn out to be true for everyone, there was a significant backlash.

Progressive analysts thus have turned to how a single-payer system might come about more gradually. But longer transition times don’t solve the core problem.

Let’s say the federal government sets up a “public option,” as it sometimes is called. Individuals would have the opportunity to buy into government insurance at some price. The new government program would be competing with private insurance, but just how good will the new benefits be? If you’re healthy and have other coverage, you probably won’t switch — if you did, that would be a sign that the new government program was of very high quality and probably too expensive for the nation as a whole. Boosting the health care of the best-covered Americans isn’t the policy priority right now.

Instead, the public option might be set up to attract those who don’t already have good coverage. But those are the same people who don’t have the money to pay a fair market price for health insurance now. In essence, the program would come to resemble a Medicaid expansion, whether or not it would fall under the formal rubric of Medicaid.

That’s a plausible option for a marginal change; many states, of course, have already done a Medicaid expansion. The question remains whether such a program can evolve into single-payer health insurance. The answer is probably not. To become a single-payer system, as coverage climbs up the income ladder, the new reform would have to lure Americans out of private health insurance. It either has to make the private alternative worse, say by penalties like a stiff “Cadillac tax” on policies that exceed a certain level, or it has to make the public alternative especially appealing. We are then back to the change either being unpopular or spending too much money on people who already have decent coverage.

You can make a good case for continuing the forthcoming Cadillac tax on private insurance, as is embedded in Obamacare. But the point of that change was to get people to move to less health insurance coverage and to use less health-care resources, not to bounce them into a system with yet lower marginal cost for a doctor’s visit or extra medical procedures.

It’s worth thinking through why some single-payer systems, such as those on the European continent or in Hong Kong and Taiwan, seem to work. Typically those systems were instituted while health-care costs were still fairly low, and then kept down by government fiat. The U.S. is not in that position, and it’s hard to see doctors and hospitals — powerful lobbies — going along with significant cuts to their payments.

Single-payer systems can work for yet another reason: If a citizenry consumes much less health care, and it doesn’t damage patient outcomes so much. Patient queuing isn’t a disaster if people who really need treatment get priority, as is the case in the better-run single-payer systems. In other words, single payer has to be sold as a way of getting us all to cut back on the consumption of medical resources. Unfortunately, the Medicare for All movement is more about easing everyone’s access and boosting the usage of health-care resources, a typically American approach.

When it comes to access, the major problem in the U.S. is distributional: Some of the poor have insufficient access, and arguably some of the well-off receive health care at too low a user price. Given Americans’ love for consumption, it’s probably too late to fix the latter problem. We can, to some extent, improve lower-income access by Medicaid expansions.

The political war along the way to a full single-payer system is unlikely to be rewarding. According to one poll, single payer is supported by only 43 percent of Americans, hardly enough to overcome political gridlock.

Progress will come in bits and pieces. The notion of a universal cure-all is a myth, whether it comes to improving your health or improving America’s health-care system.

 

Sanders’ single-payer push splits Democrats

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http://www.politico.com/story/2017/09/13/bernie-sanders-single-payer-democrats-medicare-242616

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Most liberals are on board with the bill being introduced Wednesday, but Democratic leaders and vulnerable incumbents largely steer clear.

Bernie Sanders’ single-payer health care plan has won over most other liberal senators, including many weighing 2020 bids.

The rest of the Democratic Party is another matter.

As Sanders prepares to unveil his Medicare for All legislation on Wednesday, most of the party’s congressional leaders and vulnerable Senate incumbents are steering clear. Even as the left celebrates Sanders’ ability to push the Democratic agenda leftward after his primary challenge to Hillary Clinton last year, that success appears to have its limits.

Senate Minority Leader Chuck Schumer told reporters that he would be “looking at all of” the party’s “many good” proposals to expand health care access, but declined to back Sanders. House Minority Leader Nancy Pelosi declared that her priority is shielding Obamacare from a GOP repeal push that’s not yet dead for good.

Connecticut Sen. Chris Murphy, one of the few Democrats subject to 2020 speculation who has not signed on to the Sanders bill, warned against letting the party’s attention slip to “longer-term health care policy” while the future of the Affordable Care Act remains up for debate.

“I think the risk is that we get distracted,” Murphy told reporters. “September’s not done. They can still ram through a repeal bill.”

Wisconsin Sen. Tammy Baldwin on Tuesday became the single-payer bill’s first supporter from the class of Senate Democrats up for reelection next year in states Trump carried. But other politically imperiled incumbent Democrats have said no to Sanders.

Sen. Claire McCaskill said in a brief interview that lawmakers have more work to do to keep health care costs in check “before we would think about expanding that [Medicare] system to everyone.”

Single-payer on a national level would have “a lot of problems,” McCaskill added, although she came out in support of allowing individuals as young as 55 to buy into Medicare. That idea is also backed by Baldwin and two other red-state Democrats up for reelection next year who are declining to endorse Sanders’ bill: Sens. Sherrod Brown of Ohio and Debbie Stabenow of Michigan.

Stabenow, also a member of Democratic leadership, said Tuesday that she would keep working on her Medicare-at-55 plan “because I think there is some bipartisan interest in that.” She said the party’s first order of business should be shoring up the Obamacare markets, followed by other goals.

“The first thing has to be to protect the health care people have now and stabilize markets, no question,” Stabenow said. “But we need to focus on lowering the cost of prescription drugs and providing more health care, more health care options.”

Improving the Affordable Care Act is the core of a bipartisan effort in the Senate health committee. The panel’s ranking member, Sen. Patty Murray of Washington, a member of the Democratic leadership, also declined to endorse Sanders’ bill on Tuesday.

“There’s a lot of Democratic ideas out there, and I haven’t had the chance to look at all of them,” Murray said, adding that she remains “very focused” on the committee’s work.

Republicans have already seized on the high costs of imposing a single-payer system — which Sanders’ presidential campaign proposed to pay for with new taxes on employers and wealthy individuals — to hammer Democrats for supporting the idea. The National Republican Senatorial Committee criticized Baldwin on Tuesday for backing “the left’s radical plans for government-run health care.”

Sen. John Barrasso (R-Wyo.), a member of GOP leadership, also reminded reporters Tuesday that Sanders’ home state of Vermont had to back away from its own single-payer health proposal after the economic burden proved too onerous.

Backers of the Sanders bill acknowledge that single-payer is a heavy political lift but describe it as an important benchmark for Democrats’ future. As the party hones its identity beyond opposition to Trump’s agenda, single-payer fans see enough room to set big long-term goals while waging the shorter-term battle to protect Obamacare.

“There’s nothing about the politics of the moment or the Affordable Care Act that in any way precludes supporting Medicare-for-all as the ultimate goal, and there’s a clear path to it,” said Sen. Richard Blumenthal. The Connecticut Democrat signed on to the bill Tuesday.

Sen. Al Franken (D-Minn.), who has been mentioned as a possible 2020 candidate, also expects to sign on to the single-payer bill, a spokesman said Tuesday. Franken noted that his cosponsorship reflects the bill’s status as a long-term goal while the party continues short-term work on Obamacare.

“This bill is aspirational, and I’m hopeful that it can serve as a starting point for where we need to go as a country,” Franken said in a statement. “In the short term, however, I strongly believe we must pursue bipartisan policies that improve our current health care system for all Americans — and that’s exactly what we’re doing right now in the Senate Health Committee, on which both Senator Sanders and I sit.”

For other Democrats, however, the idea’s time may have not yet come.

Ben Cardin said in an interview that he supports universal health coverage but has “certain concerns” about using single-payer to achieve that goal.

“There’s the political issue, but there’s also the issue about how you make sure there will be adequate resources put into health care,” the Maryland Democrat said.

Sen. Joe Manchin of West Virginia, a member of leadership who’s among the GOP’s top targets in 2018, walked a fine line Tuesday as Republicans revived his past comments welcoming a discussion of a government-run health care system.

“I am skeptical that single-payer is the right solution, but I believe that the Senate should carefully consider all of the options through regular order so that we can fully understand the impacts of these ideas on both our people and our economy,” Manchin said in a statement on Tuesday.

Sen. Dianne Feinstein, facing consternation from liberals in her home state of California — where an effort to enact single-payer statewide ran aground this year — said that she would want to see the price tag before taking a position on Sanders’ bill.

“My understanding is, the cost of single-payer is enormous,” Feinstein said, noting that she supports a public option for health insurance outside the private market.

Murphy and Hawaii Sen. Brian Schatz have offered their own ideas to shift the party’s health care debate leftward without going as far as Sanders’ plan would. The Connecticut Democrat is working on legislation creating a Medicare buy-in for all individuals and businesses, while Schatz told POLITICO he expects to release a Medicaid buy-in proposal later this month.

Murphy said he would not sign on to Sanders’ bill before its release, urging “our party to take some time and look at all the options available to us before we decide on one unitary route.”

And even as some Sanders-aligned activists spook Democrats with talk of possible primary challenges to candidates who don’t support the single-payer plan, other liberals were content to cheer the Vermont independent for attracting more than one-quarter of the caucus to his legislation. Progressive Change Campaign Committee co-founder Adam Green, who worked with Murphy on the Medicare buy-in plan, said that “Democrats are increasingly wrapping themselves in the flag of” Medicare for all without closing off other options that advance the ball.

“This is how big ideas like expanding Social Security and debt-free college were moved into the mainstream — the North Star gets put up, solid organizing is done, critical mass is built in Congress and on the campaign trail, and party consensus falls into place,” Green said by email. “It’s happening now.”

The Real Reason the U.S. Has Employer-Sponsored Health Insurance

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The basic structure of the American health care system, in which most people have private insurance through their jobs, might seem historically inevitable, consistent with the capitalistic, individualist ethos of the nation.

In truth, it was hardly preordained. In fact, the system is largely a result of one event, World War II, and the wage freezes and tax policy that emerged because of it. Unfortunately, what made sense then may not make as much right now.

Well into the 20th century, there just wasn’t much need for health insurance. There wasn’t much health care to buy. But as doctors and hospitals learned how to do more, there was real money to be made. In 1929, a bunch of hospitals in Texas joined up and formed an insurance plan called Blue Cross to help people buy their services. Doctors didn’t like the idea of hospitals being in charge, so some in California created their own plan in 1939, which they called Blue Shield. As the plans spread, many would purchase Blue Cross for hospital services, and Blue Shield for physician services, until they merged to form Blue Cross and Blue Shield in 1982.

Most insurance in the first half of the 20th century was bought privately, but few people wanted it. Things changed during World War II.

In 1942, with so many eligible workers diverted to military service, the nation was facing a severe labor shortage. Economists feared that businesses would keep raising salaries to compete for workers, and that inflation would spiral out of control as the country came out of the Depression. To prevent this, President Roosevelt signed Executive Order 9250, establishing the Office of Economic Stabilization.

This froze wages. Businesses were not allowed to raise pay to attract workers.

Businesses were smart, though, and instead they began to use benefits to compete. Specifically, to offer more, and more generous, health care insurance.

Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means.

After World War II, Europe was devastated. As countries began to regroup and decide how they might provide health care to their citizens, often government was the only entity capable of doing so, with businesses and economies in ruin. The United States was in a completely different situation. Its economy was booming, and industry was more than happy to provide health care.

This didn’t stop President Truman from considering and promoting a national health care system in 1945. This idea had a fair amount of public support, but business, in the form of the Chamber of Commerce, opposed it. So did the American Hospital Association and American Medical Association. Even many unions did, having spent so much political capital fighting for insurance benefits for their members. Confronted by such opposition from all sides, national health insurance failed — for not the first or last time.

In 1940, about 9 percent of Americans had some form of health insurance. By 1950, more than 50 percent did. By 1960, more than two-thirds did.

One effect of this system is job lock. People become dependent on their employment for their health insurance, and they are loath to leave their jobs, even when doing so might make their lives better. They are afraid that market exchange coverage might not be as good as what they have (and they’re most likely right). They’re afraid if they retire, Medicare won’t be as good (they’re right, too). They’re afraid that if the Affordable Care Act is repealed, they might not be able to find affordable insurance at all.

This system is expensive. The single largest tax expenditure in the United States is for employer-based health insurance. It’s even more than the mortgage interest deduction. In 2017, this exclusion cost the federal government about $260 billion in lost income and payroll taxes. This is significantly more than the cost of the Affordable Care Act each year.

This system is regressive. The tax break for employer-sponsored health insurance is worth more to people making a lot of money than people making little. Let’s take a hypothetical married pediatrician with a couple of children living in Indiana who makes $125,000 (which is below average). Let’s also assume his family insurance plan costs $15,000 (which is below average as well).

The tax break the family would get for insurance is worth over $6,200. That’s far more than a similar-earning family would get in terms of a subsidy on the exchanges. The tax break alone could fund about two people on Medicaid. Moreover, the more one makes, the more one saves at the expense of more spending by the government. The less one makes, the less of a benefit one receives.

The system also induces people to spend more money on health insurance than other things, most likely increasing overall health care spending. This includes less employer spending on wages, and as health insurance premiums have increased sharply in the last 15 years or so, wages have been rather flat. Many economists believe that employer-sponsored health insurance is hurting Americans’ paychecks.

There are other countries with private insurance systems, but none that rely so heavily on employer-sponsored insurance. There are almost no economists I can think of who wouldn’t favor decoupling insurance from employment. There are any number of ways to do so. One, beloved by wonks, was a bipartisan plan proposed by Senators Ron Wyden, a Democrat, and Robert Bennett, a Republican, in 2007. Known as the Healthy Americans Act, it would have transitioned everyone from employer-sponsored health insurance to insurance exchanges modeled on the Federal Employees Health Benefits Program.

Employers would not have provided insurance. They would have collected taxes from employees and passed these onto the government to pay for plans. Everyone, regardless of employment, would have qualified for standard deductions to help pay for insurance. Employers would have been required to increases wages over two years equal to what had been shunted into insurance. Those at the low end of the socio-economic spectrum would have qualified for further premium help.

This isn’t too different from the insurance exchanges we see now, writ large, for everyone. One can imagine that such a program could have also eventually replaced Medicaid and Medicare.

There was a time when such a plan, being universal, would have pleased progressives. Because it could potentially phase out government programs like Medicaid and Medicare, it would have pleased conservatives. When first introduced in 2007, it had the sponsorship of nine Republican senators, seven Democrats and one independent. Such bipartisan efforts seem a thing of the past.

We could also shift away from an employer-sponsored system by allowing people to buy into our single-payer system, Medicare. That comes with its own problems, as The Upshot’s Margot Sanger-Katz has written. She also has covered the issues of shifting to a single-payer system more quickly.

It’s important to point out that neither of these options has anything even close to bipartisan support.

Without much pressure for change, it’s likely the American employer-based system is here to stay. Even the Affordable Care Act did its best not to disrupt that market. While the system is far from ideal, Americans seem to prefer the devil they know to pretty much anything else.