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Bernie Sanders’s single-payer plan isn’t a plan at all

F6, the three excellent articles here all enhance your positive yet realistic comment on Bernie (who incidentally yesterday i was thinking in a sense could
be seen as a man still ahead of his time in the U.S.A), and are included in one post here for the same reason you compose your fulfilling lengthy ones.

Sanders's long-awaited health care plan is, by turns, vague and unrealistic.

Updated by Ezra Klein on January 17, 2016, 11:00 p.m. ET @ezraklein


Photo by Andrew Burton/Getty Images

Hillary Clinton has made a lot of bad arguments .. http://www.vox.com/2016/1/15/10775420/hillary-clinton-doesnt-trust-you .. about Bernie Sanders's support for single-payer. But her best argument was her simplest: With mere weeks to go before the Iowa caucuses, Sanders still hadn't released any details about his plan. And absent a real plan no one could really say what he was proposing, or whether it was a good idea. As Clinton said in an interview with MSNBC's Rachel Maddow, "the devil's in the details when it comes to health care."

On Sunday night, mere hours before the fourth Democratic debate, Sanders tried to head off Clinton's attacks by releasing his plan .. https://berniesanders.com/wp-content/uploads/2016/01/Medicare-for-All.pdf . Only what he released isn't a plan. It is, to be generous, a gesture towards a future plan.

To be less generous — but perhaps more accurate — this is a document that lets Sanders say he has a plan, but doesn't answer the most important questions about how his plan would work, or what it would mean for most Americans. Sanders is detailed and specific in response to the three main attacks Clinton has launched, but is vague or unrealistic on virtually every other issue. The result is that he answers Clinton's criticisms while raising much more profound questions about his own ideas.

Sanders promises his health-care system will cover pretty much everything while costing the average American almost nothing, and he relies mainly on vague "administrative" savings and massive taxes on the rich to make up the difference. It's everything critics fear a single-payer plan would be, and it lacks the kind of engagement with the problems of single-payer health systems necessary to win over skeptics.

What Sanders's plan tells us that we didn't know before

Clinton's first attack was that Sanders hadn't released a plan. Now he has.

Clinton's second attack was that Sanders would rely on states to manage and partially finance his health-care system, as he's proposed in the past. His plan puts that criticism completely to rest, clarifying that the system will be "federally administered." As far as this document goes, there is no role for states at all.

Clinton's third attack was that Sanders's plan would raise taxes on the middle class. In response, Sanders gets very detailed on the financing of his plan. It would raise taxes on the middle class — in part through a 2.2 percent tax increase on all income, and in part by a 6.2 percent "income-based premium" on employers (which would, in turn, get passed onto workers through lower wages and higher prices).

The rest of the financing would come through a raft of new taxes on the rich. Sanders would raise marginal rates on income over $250,000, he would raise the tax rate on capital gains and dividend income, he would hike the estate tax, and he would close sundry deductions and loopholes.

In general, I'm comfortable with higher taxes on the rich — though they've risen substantially in the Obama era already — but tax increases of the scale Sanders proposes here would begin to have real economic drawbacks. European countries tend to pay for their health-care systems through more broad-based, economically efficient taxes like VATs; Sanders's effort to fund a universal health-care system so heavily on the backs of the wealthy would be unprecedented.

All in all, Sanders wants to raise taxes by a bit over a trillion dollars per year — which may not sound like much to those who remember the Obamacare debate, but remember that the numbers that got thrown around for Obamacare were 10-year estimates. Adding inflation, Sanders will be raising taxes by close to $15 trillion when the Congressional Budget Office applies its normal scoring window.

Of course, these new taxes replace the premiums Americans pay now. Here, Sanders promises that between shifting health-care financing to the rich and cutting costs through single-payer's efficiencies, his plan will only cost the average American family around $450 — a savings of more than $5,800 over what they're paying in premiums now.

Those benefits are big. To get them, Sanders is assuming some immense cost savings. And that's where the problems start.

Sanders's plan isn't Medicare-for-All


Photo by Andrew Burton/Getty Images

Sanders calls his plan Medicare-for-All. But it actually has nothing to do with Medicare. He's not simply expanding Medicare coverage to the broader population — he makes that clear when he says his plan means "no more copays, no more deductibles"; Medicare includes copays and deductibles. The list of what Sanders's plan would cover far exceeds what Medicare offers, suggesting, more or less, that pretty much everything will be covered, under all circumstances.

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Bernie's plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs.
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Sanders goes on to say that his plan means "no more fighting with insurance companies when they fail to pay for charges."

To be generous, it's possible that Sanders is just being cynical in his wording, and what he means is that, under his plan, individuals have to fight with the government rather than private insurers when their claims are denied.

But the implication to most people, I think, is that claim denials will be a thing of the past — a statement that belies the fights patients have every day with public insurers like Medicare and Medicaid, to say nothing of the fights that go on in the Canadian, German, or British health-care systems.

What makes that so irresponsible is that it stands in flagrant contradiction to the way single-payer plans actually work — and the way Sanders's plan will have to work if its numbers are going to add up.

Behind Sanders's calculations, both for how much his plan will cost and how much Americans will benefit, lurk extremely optimistic promises about how much money single-payer will save. And those promises can only come true if the government starts saying no quite a lot — in ways that will make people very, very angry.

What Sanders doesn't tell us that we really need to know
Photo by Andrew Burton/Getty Images
Sanders answered Clinton's criticisms, but he didn't answer the most important questions about his plan.

"They assumed $10 trillion in health-care savings over ten years," says Larry Levitt, vice president at the Kaiser Family Foundation. "That’s tremendously aggressive cost containment, even after you take the administrative savings into account."

The real way single-payer systems save money isn't through cutting administrative costs. It's through cutting reimbursements to doctors, hospitals, drug companies, and device companies .. http://www.vox.com/2016/1/15/10775050/single-payer-debate . And Sanders's gestures towards this truth in his plan, saying that "the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively."

But to get those savings, the government needs to be willing to say no when doctors, hospitals, drug companies, and device companies refuse to meet their prices, and that means the government needs to be willing to say no to people who want those treatments. If the government can't do that — if Sanders is going to stick to the spirit of "no more fighting with insurance companies when they fail to pay for charges" — then it won't be able to control costs.

The issue of how often the government says no leads to all sorts of other key questions — questions Sanders is silent on. For instance, who decides when the government says no? Will there be a cost-effectiveness council, like Britain's National Institute for Health and Care Excellence? Or will the government basically have to cover every treatment that can be proven beneficial, as is true for Medicare now? What will the appeals process be like?

This might sound technical, but it's absolutely critical. Sanders implies everything will be covered because he knows how important that question is to people. But everything won't be covered. So who decides, how do they decide, what gets covered, and what doesn't? Without knowing that, it's impossible to say whether a particular single-payer system is a good idea or a really, really bad one.

Another crucial question is whether Sanders envisions the possibility of exit inside his system. Technically, a single-payer system is a system with, well, a single payer. Private insurers are outlawed — otherwise, it would be a multi-payer system. But the term is often used more loosely than that, and many systems that get mentioned during discussions of single-payer, like the French system, include various kinds of supplementary, private insurance that people generally purchase.

The role of private insurers matters because it drives the government's bargaining power. If drug companies either sell to the government or they go out of business, then the government can get better prices. The problem there is obvious, though: What does someone do if the government doesn't cover a treatment they need? But if there are private insurers selling add-on policies to wealthier Americans, then drug companies can deal only with them, and the government's negotiating power wanes.

Another question Sanders's plan doesn't answer but is crucially important: How do you guarantee physical access to medical care? Right now, hospitals charge Medicaid one price, Medicare a somewhat higher price, and private insurers an even higher price. If the entire system is squeezed down to Medicare pricing, a lot of hospitals are going to close. How will Sanders keep that from happening? Or will he let it happen, even if it means people in rural areas need to drive hours for care?

The easy rejoinder to this is that this is just a campaign proposal, and these are details that can be worked out in the legislative process. I disagree. Sanders is proposing a huge, disruptive reform here — he owes the public answers to the most central, obvious questions about how that reform would work. Perhaps more importantly, he also needs to show that he's at least aware of the difficulties of a single-payer system, and has realistic ideas for managing the transition.

Moreover, the fundamental debate between Sanders and Hillary Clinton — and Sanders and the GOP — is whether single-payer is a good idea at all. That debate can't be resolved unless these kinds of questions are answered.

In the absence of these kinds of specifics, Sanders has offered a puppies-and-rainbows .. http://www.nytimes.com/2015/03/12/upshot/marco-rubios-puppies-and-rainbows-tax-plan.html?_r=0 .. approach to single-payer — he promises his plan will cover everything while costing the average family almost nothing. This is what Republicans fear liberals truly believe: that they can deliver expansive, unlimited benefits to the vast majority of Americans by stacking increasingly implausible, and economically harmful, taxes on the rich. Sanders is proving them right.

A few days ago, I criticized .. http://www.vox.com/2016/1/15/10775420/hillary-clinton-doesnt-trust-you .. Hillary Clinton for not leveling with the American people. She seemed, I wrote, "scared to tell voters what she really thinks for fear they'll disagree." Here, Sanders shows he doesn't trust voters either. Rather than making the trade-offs of a single-payer plan clear, he's obscured them further. In answering Clinton's criticisms, he's raised real concerns about the plausibility of his own ideas. .. http://www.vox.com/2016/1/17/10784528/bernie-sanders-single-payer-health-care

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That's the first by the insightful Ezra Klein The second from the equally erudite Paul Krugman.

Health Reform Realities

Paul Krugman JAN. 18, 2016

Health reform is the signature achievement of the Obama presidency. It was the biggest expansion of the social safety net since Medicare .. http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier .. was established in the 1960s. It more or less achieves a goal — access to health insurance .. http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/index.html?inline=nyt-classifier .. for all Americans — that progressives have been trying to reach for three generations. And it is already producing dramatic results, with the percentage of uninsured Americans falling to record lows .. http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201511.pdf .

Obamacare is, however, what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.

The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.

My answer, as you might guess, is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues — that is, that Bernie Sanders is wrong about this and Hillary Clinton is right. But the main point is that we should think clearly about why health reform looks the way it does.

If we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone. But single-payer wasn’t a politically feasible goal in America, for three big reasons that aren’t going away.

First, like it or not, incumbent players have a lot of power. Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business.

Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.

Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.

What this means, as the health policy expert Harold Pollack .. http://www.vox.com/2016/1/16/10779270/pollack-single-payer-in-america .. points out, is that a simple, straightforward single-payer system just isn’t going to happen. Even if you imagine a political earthquake that eliminated the power of the insurance industry and objections to higher taxes, you’d still have to protect the interests of workers with better-than-average coverage, so that in practice single-payer, American style, would be almost as kludgy as Obamacare.

Which brings me to the Affordable Care Act, which was designed to bypass these obstacles. It was careful to preserve and even enlarge the role of private insurers. Its measures to cover the uninsured rely on a combination of regulation and subsidies, rather than simply on an expansion of government programs, so that the on-budget cost is limited — and can, in fact, be covered without raising middle-class taxes. Perhaps most crucially, it leaves employer-based insurance intact, so that the great majority of Americans have experienced no disruption, in fact no change in their health-care experience.

Even so, achieving this reform was a close-run thing: Democrats barely got it through during the brief period when they controlled Congress. Is there any realistic prospect that a drastic overhaul could be enacted any time soon — say, in the next eight years? No.

You might say that it’s still worth trying. But politics, like life, involves trade-offs.

There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. Indeed, room for maneuver will be limited even if a post-Trump Republican Party moves away from the scorched-earth opposition it offered President Obama .. http://topics.nytimes.com/top/reference/timestopics/people/o/barack_obama/index.html?inline=nyt-per .

So progressives must set some priorities. And it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years. .. http://www.nytimes.com/2016/01/18/opinion/health-reform-realities.html?_r=1

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To wrap it up for now, Jeet Heer of the New Republic

You Say You Want a Revolution, Bernie?



Sanders's theory of political change isn't as plausible as Hillary Clinton's.

By Jeet Heer January 18, 2016

Max Weber, the great sociologist best remembered for coining the phrase “Protestant work ethic,” would have loved Sunday’s Democratic debate. Leaving aside the sad and quixotic figure of Martin O’Malley .. https://newrepublic.com/minutes/127897/martin-omalley-still-remind-everyone-name-is , the two main contenders Hillary Clinton and Bernie Sanders perfectly illustrated a distinction Weber made in his classic 1919 essay .. http://anthropos-lab.net/wp/wp-content/uploads/2011/12/Weber-Politics-as-a-Vocation.pdf .. “Politics as a Vocation .. http://anthropos-lab.net/wp/wp-content/uploads/2011/12/Weber-Politics-as-a-Vocation.pdf .” In that essay, Weber distinguished between two different ethical approaches to politics, an “ethics of moral conviction” and an “ethics of responsibility.”

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Signal

"Sanders has a much tougher and deeper analysis than Clinton of how
fundamental America’s problems are. The question is, how plausible
is his prescription of political revolution as a solution?"
Jeet Heer
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Sanders is promoting an “ethics of moral conviction” by calling for a “political revolution” seeking to overthrow the deeply corrupting influence of big money on politics by bringing into the system a counterforce of those previously alienated, including the poor and the young. Clinton embodies the “ethics of responsibility” by arguing that her presidency won’t be about remaking the world but trying to preserve and build on the achievements of previous Democrats, including Obama.

The great difficulty Sanders faces is that given the reality of the American political system (with its divided government that has many veto points) and also the particular realities of the current era (with an intensification of political polarization making it difficult to pass ambitious legislation through a hostile Congress and Senate), it is very hard to see how a “political revolution” could work.

The differences between Sanders and Clinton were acutely visible when they debated the issue of health care .. https://newrepublic.com/minutes/127908/hillary-clinton-finally-affirmed-positive-vision-health-care-bear-hugging-obama . “Politics is a strong and slow boring of hard boards,” Weber wrote. That’s an almost perfect description of how Clinton approaches politics. Clinton’s core argument was that Sanders’s call for “Medicare for all” would jeopardize all that Democrats have achieved through the decades-long strong and slow boring of hard boards that it took to get Medicare and Obamacare. “What I’m saying is really simple,” Clinton argued on stage. “This has been the fight of the Democratic Party for decades. We have the Affordable Care Act. Let’s make it work.”

As against this call for responsible stewardship, Sanders forcefully articulated his moral conviction that a better system could be achieved by a politics that tackled the corruption of big money. “Do you know why we can’t do what every ... major country on Earth is doing?” Sanders asked. “It’s because we have a campaign finance system that is corrupt, we have super PACs, we have the pharmaceutical industry pouring hundreds of millions of dollars into campaign contributions and lobbying, and the private insurance companies as well.”

Sanders has a much tougher and deeper analysis than Clinton of how fundamental America’s problems are. The question is, how plausible is his prescription of political revolution as a solution?

Slate’s Jamelle Bouie wrote one of the sharpest dissections we have of Sanders’s theory of political change and found some serious problems .. http://www.slate.com/articles/news_and_politics/politics/2015/10/bernie_sanders_theory_of_change_isn_t_serious_the_vermont_senator_s_political.html :

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On Thursday, I argued .. http://www.slate.com/articles/news_and_politics/politics/2015/10/hillary_clinton_would_make_a_better_president_than_bernie_sanders_the_democratic.html .. that both Hillary Clinton and Sanders need to give plans for executive branch action, given gridlock in Congress. In response, on Twitter, some Sanders supporters said this was wrong: That Sanders—with a long career in lawmaking .. https://twitter.com/ebruenig/status/654832746800488448 —could win Republican support; that Sanders would use the bully pulpit to rally voters .. https://twitter.com/jonesjeffum/status/654833521031270400 ; and that a Sanders win would necessarily bring the kind of wave .. https://twitter.com/politigamer/status/654837505557188608 .. that would give him votes for his policies.

But this is blind to reality. Compromise is a distant shore. The Democratic Party has moved to the left, and the Republican Party has made a sharp turn to the right, guided by two generations of conservative revolutionaries, from Newt Gingrich to the Tea Party tidal wave of 2010. If you watched the Republican and Democratic debates back to back, you’d be forgiven for thinking they described two different countries. What’s more, as demonstrated by the GOP presidential race—as well as the leadership fracas in the House of Representatives—many Republicans (57 percent, according to the Pew Research Center) reject compromise full stop. The world where Donald Trump and Ben Carson lead the GOP presidential race is not a world where Republican voters would support a Democratic president or assent to his policies.

The presidency is polarizing .. http://www.researchgate.net/publication/231746261_Dividers_Not_Uniters_Presidential_Leadership_and_Senate_Partisanship_1981-2004 . When you step onto its field, you become a polarized figure.
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Sanders has convincingly argued that America needs a political revolution. And with his full-throttle “ethics of moral conviction” Sanders is proving to be an inspiring leader in the push for that movement. But given the way American politics works now, electing Sanders won’t achieve that revolution, which is why many voters will stick to Clinton’s more plausible politics of responsibility.

Jeet Heer is a senior editor at the New Republic. @HeerJeet
https://newrepublic.com/article/127925/say-want-revolution-bernie

See also:

On good guy Bernie, i tried to touch on the feeling here

ending tax-payer subsidies for private health insurance and for pharmacy purchase (so could be seen
as for corps, too?) the most debatable and guessing would be a very long time, if ever eventuate
http://investorshub.advfn.com/boards/read_msg.aspx?message_id=119853928

here

between the two on Wall Street today i'm thinking the difference could now be as much a populist notion as anything of substance which could
become reality .. surely if you picture what either could hope to get through congress in real terms there may not be much 'real' difference at all.
http://investorshub.advfn.com/boards/read_msg.aspx?message_id=119902057

and here

politics is more a marathon
http://investorshub.advfn.com/boards/read_msg.aspx?message_id=119905381