She has led the way, but all the
candidates need to come clean about their health care proposals.
By Elisabeth Rosenthal
November 6, 2019
Laying
the table for the next Democratic debate, Massachusetts Sen. Elizabeth Warren
has issued a plan that explains how she would fund what she calls Medicare for
All. She had studiously avoided saying whether it would raise taxes for the
middle class, and in her proposal, she says (repeatedly) it will not.
It will
instead be financed by a mix of wealth taxes, employer transfers of money they
currently spend on health care and reductions of the many inefficiencies in our
current byzantine system — among other initiatives.
But now
all the candidates need to tell us more of those details about their health
care strategies. It’s time for the candidates to stop talking slogans and start
talking sense — or dollars and cents — so that voters can know what they mean
and choose among them.
Medicare
for All, Medicare for All Who Want It, a public option, improving the
Affordable Care Act — those are 30,000-foot concepts that, depending on the
details, could work (or not) and be popular (or not).
The
candidates (including Warren) also need to say more about what they’ll do right
now: In one poll, 40 percent of Americans said they had skipped a recommended
test or treatment, and 32 percent said they had skipped a medicine, because of cost.
Supporters
of Medicare for All want to tie their future to the popularity of the Medicare
program. But Warren (and Sen. Bernie Sanders) are offering up Americans a supercharged version of
the current government insurance for those over 65.
It
promises to eliminate copayments for prescription drugs. (Under current
Medicare, many patients contribute thousands of dollars annually.) It includes
dental and long-term care — a huge expense that is conspicuously missing from
current Medicare.
That
ambition would make a health care plan vastly more expensive. The national
health systems of Britain and Canada, both single
payer systems like the Medicare for All proposal, do not offer comprehensive
long-term care coverage. Canada’s system, where benefits vary somewhat by
province, doesn’t generally include prescription drug coverage out of the
hospital for adults under 65.
Is the
financing Warren proposes going to be adequate to support the expanded goals?
Economists disagree.
But in
releasing her proposal, she has thrown down the gauntlet before the other
candidates — who support Medicare for All Who Want It or some other type of
public option — to be a whole lot clearer about what they mean.
Joe
Biden, Kamala Harris, Pete Buttigieg, et al.: Does your public option — a
government insurance policy that anyone may buy — resemble Sanders’s enhanced
Medicare, or current Medicare or Medicaid, which is far more bare bones?
Voters
need to know.
There’s
another obvious reason the candidates have been so close lipped on specifics:
To calculate how to pay for any of the plans, the candidates have to say how
they intend to bring down prices — for hospital stays, drugs, procedures,
devices, doctors’ visits, surgeries. Americans often pay two to 10 times what
patients pay for these items in other developed countries.
Those
prices will have to come down to make any plan viable without breaking the
bank. To really assess any plan, we’ll need that kind of information.
Warren
has courageously stepped into that fraught territory, with numbers that have
very likely sent shock waves through the health care industry.
For
example, to make her financing proposal work, she suggests paying most
hospitals on average 110 percent of current Medicare rates. She suggests
Americans should pay no more for drugs than 110 percent of the average
international market price. That may be eminently reasonable, but is it
achievable?
When
Montana negotiated rates directly with hospitals for its state employees, it settled on a deal in
which the state agreed to pay an average of 234 percent of Medicare rates. And
it still saved money.
Setting
lower prices is going to bring out strong opposition. Remember, patient (or
taxpayer) savings mean loss of income for one of America’s most profitable
industries, whose lobbyists spent more than half a billion dollars last year
and which is flush with dark money to distribute in Congress.
To get
the ACA passed, President Barack Obama gave up on a number of price-lowering
ideas to get buy-in from the health care industry and its friends in Congress.
These included jettisoning the idea of a public option and allowing Medicare to
negotiate drug prices.
The
Republicans — whose “plans” have been largely proclamations of better, cheaper
health care without any strategy — will be quick to label any of the Democratic
plans as a government takeover of health care, or socialism.
Remember,
patient (or taxpayer) savings mean loss of income for the United States’ most robust sector in the
post-recession economy. In many post-manufacturing cities like Pittsburgh and Cleveland, a single
hospital system is the biggest employer. In Boston, hospitals and hospital
corporations make up the top six employers.
Minnesota and Massachusetts have done well with drug and device manufacturing.
And let’s not start on insurers, whose lucrative health business would largely
disappear.
Any
plan to rein in the United States’ bloated $3.5 trillion health care system
will be slow going, requiring not just a footnoted blueprint but also the
taming of many opposing forces. It took years for Canada to move from a market-based system to
government run health. It endured lengthy debates and doctors’
strikes.
Warren
calls her proposal a “long-term plan.” But voters want to know how we get from
here to anywhere else. In polls, their top health care issue is affordability — emphasis
on now.
They
need concrete proposals as well as long-term vision. In the next debate, how
about talking about H.R. 3, a bill in Congress to curb
prescription drug prices? That plan would allow the health and human services
secretary to negotiate a maximum price that could be charged to Medicare for
insulin and some of the most expensive medicines in the United States, based on
the prices paid for those drugs in other countries.
Days
before the last Democratic debate, the Congressional Budget Office said it would save $345 billion over a
six-year period (2023-29).
If the
bill were to move to the Senate, how would the front-runners vote? What do they
have to say about that?
Elisabeth
Rosenthal: erosenthal@kff.org,
@rosenthalhealth
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