The Aspiration of Medical for All

Terry H. Schwadron

Nov. 8, 2019

We have Elizabeth Warren’s responses to her fellow Democratic opponents to thank for making the Medicare for All discussion a bit more juicy.

To her credit or expense, she rose to the challenge to lay out financial parameters for her vision of a government, single payer health system that will halt the continuous rise of costs and extend coverage as an American right. It’s to her credit, of course, that doing so is both difficult to sketch out though it leaves her vulnerable to endless questioning about one figure or another.

In some corners, it would have been easier, as it has been for Bernie Sanders, to set the vision as aspirational while acknowledging that announcement of any such plan would have to change markedly through the inevitably tortured legislative process.

My concern is this: While Democratic candidates nip at one another over the best vision for Medicare for all, Donald Trump administration is busily getting rid of the Affordable Care Act. If a current court case in a Texas federal court proves successful for the administration — Trump’s Department of Justice switched sides to beef up the argument to toss the entire law — we will summarily dump 21 million families from health care altogether.

It seems to me that ought to be the target of Democrats who want to care about health care improvements. You won’t be able to improve much of anything if Trump is successful at simply having the current law null and void.

The Current Problem: Tossing Obamacare

Just to remind all, that case before the U.S. Court of Appeals for the 5th Circuit has heard oral arguments in a challenge brought by Texas and 20 other states to declare the ACA unconstitutional. The challenge argues the individual mandate portion of the law that sets a “tax” for non-participating adults was reset by 2017 Republican-majority Congress in the last session at zero, and therefore nullifies any such tax. Because the 2010 Congress had called the tax penalty essential, the whole law should be chucked.

The decision, when announced, will undoubtedly be appealed to the Supreme Court, but it is bound to cause havoc in the health insurance world, eliminating such legal provisions as requirements for pre-existing health conditions. The Department of Justice, which previously argued on behalf of the federal law, switched positions under Atty. Gen. William P. Barr with Trump’s urging.

Clearly Republicans and Trump have no health plan to substitute, but those low-cost plans that have been floated do not cover pre-existing conditions or other provisions. The Trump administration believes only that companies should pay for health care, and any public financing shortfalls should be shunted to the states.

Meanwhile, health costs to Americans — the highest in the world, for care that does not match the best outcomes in the world — continue to rise each year.

And Republicans in Congress, led by Senate Majority Leader Mitch McConnell swear to a campaign to move federal costs to the states.

Meawhile, the Democrats

All of which brings us back to the unfolding Democratic primary, in which Warren and Sanders are leading the discussion to move away from an insurance-based access to health care for a single government-paid system, fueled, naturally by taxes.

Warren and Sanders have argued that we need a fundamental change in approach away from profit-based insurance company control, for-profit drug company control of prescription drug prices, and for-profit and variable hospital prices for services. Like the Green New Deal, the idea of a more humane, more democratic, more preventive health-oriented and less profit-oriented health care system is awfully inviting. The issue, of course, is how to pay for it.

So Warren went where Bernie dared not: She took the challenge to draw out a plan to spend $20.5 trillion dollars over 10 years to achieve the vision, drawing largely on taxing the wealthy and corporations to provide the money, and moving insurers out of the mainline health business.

As many quick news organization analyses have shown, her plan likely is overly optimistic about whether such a plan would win actual legislative authority and on whether its built-in assumptions are too rosy. The criticisms say she is overly optimistic about collecting outstanding, uncollected federal taxes, about cooperation from hospitals, doctors and service providers accepting limits on reimbursement, and on reduction of prescription drug prices in some cases by upwards of 70 percent, to say nothing of persuading Jeff Bezos and Amazon to pay several billion dollars in taxes as compared with zero. She is insistent that this will not raise middle-class taxes, a doubtful claim anytime, but acknowledges that it may upset jobs in the health sector, which is another way of measuring adverse change.

OK, maybe the assumptions are too rosy, but it was an answer that others have not provided. Even at that, she has done a public service, by outlining the size of the job ahead. And by giving us a direction in which to aim.

She is also implicitly offering a counterchallenge — how much more will the current systems will cost us, with annualized increases, variable hospital and doctor prices, constantly rising drug prices.

What Warren and the rest could be outlining are plans to reduce prices now, even before we talk about who underwrites insurance. How is it that a single surgery costs ten times as much at hospital one from hospital two? How is it that pharamaceutical costs are not the subject of Medicare negotiation? How is it that doctors can decide on their own whether they will accept Medicare reimbursements, and instead now are charging separate fees for “concierge” services?

What we need is assurance that there will be a plan now in the event that the 5th Circuit court throws out Obamacare, and a stepped outline to add public options to the current Medicare and Medicaid systems with some guarantees for the marketplace. Medicare for All remains a gold standard, but if realities get in the way, we need a way for voters to understand that it comes in pieces towards that end.

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