2020: The Healthcare Debate

Healthcare is going to be most likely the most important issue of the upcoming campaigns for President and every other federal office we are going to be asked to vote on.  In a recent Fox News Poll that was released on January 26, a couple of interesting results included:

  • How approve or disapprove of the way Donald Trump is handling healthcare?

38% – Approve               54% – Disapprove             7% – Don’t Know

  • Which of the following issues do you think is the MOST important issue facing the country today?
    1. Health care                                                  13%
    2. Partisanship and lack of unity                13%
    3. Climate change                                           12%
    4. The economy and jobs                              12%
    5. Political corruption                                    12%
    6. Immigration and border security           10%
    7. Terrorism                                                       7%
    8. Gun policy                                                      6%
    9. Foreign policy                                                3%
    10. International trade                                       1%

Based on those poll results (and most polls look very similar), two things are clear:  That people are not happy with the status quo, and it is at the top of the list for issues facing Americans.

The Problem:

While healthcare is clearly an important issue and nearly everyone is talking about it, it is literally a jungle of misinformation, intentional lies, rhetoric, and as a result, millions of very confused and misinformed voters.  Part of the reason for the lack of real understanding is simply that it is a very complicated issue, but you do not have to be an expert or spend hours upon hours reading up on the subject to at least understand it in broad terms.  The bigger part of the reason for people not being clear, in my opinion, or the lies and rhetoric surrounding the topic.  I’ll get to the general understanding later, but for now I am going to focus on the biggest lies being told.

Donald Trump Lie #1

“I am the only one protecting preexisting conditions!”

Truth:  The Trump Administration right now, as you read this, has their Attorney General arguing before the Supreme Court that the Affordable Care Act should be ruled unconstitutional and eliminated completely.  In addition, because of how many millions of people this would strip of health insurance completely, they have submitted a formal request to the Supreme Court that if they do reach a decision in the near future that they withhold that decision, and do not release it until AFTER the 2020 election.  So, not only is the President flat out lying to you about what they are doing, he is actively arguing to harm millions of people AND if they are successful, trying to hide that fact until after the election because they know it would be devastating to their reelection chances.  The reason why this relates to preexisting conditions is because the only two ways that you can receive coverage for preexisting conditions currently is to buy into a group plan offered by your employer or by purchasing a plan through the ACA Marketplace.

Donald Trump Lie #2

“Democrats want to take your healthcare away!”

Truth:  Democrats are providing a lot of different plans and approaches to healthcare.  In EVERY instance, their proposals include both covering MORE people than the current system does, AND doing it for a LOWER cost.  The debate about the pros and cons of each plan is a separate argument to have, but suffice it to say, those two elements are a part of EVERY Democratic plan.  With the plans that do talk about “taking away” your healthcare, what they are specifically referring to is a program that would replace private, employer based, for-profit health insurance with a single payer system.  Below, you will see what that would mean in more specific terms, so please reserve judgement until you have read this entire article, but the one thing to try to keep in mind in the meantime is that in every developed nation that has implemented their version of a single payer system, a few things are true:

    1. The total cost of providing healthcare to 100% of their population is FAR LESS than the total cost of what the United States spends to cover much less than 100% of our population.
    2. In these countries, the results are significantly better, as these countries with a single payer system frequently have a longer average life expectancy than the United States, and not only that, but in ALL OF THEM, their average life expectancy is increasing each year, whereas in the United States, it has begun to decrease in recent years.

General Lie #1

“We cannot afford to implement a single payer healthcare system!  It is far too expensive!”

Truth:  In literally EVERY credible study done on the subject, a single payer healthcare system in the United States would REDUCE the overall cost of providing healthcare to Americans.  When you look a the total number, it is HUGE, but what the naysayers never explain is that currently, we spend more than that when you add up all of the different sources of funding that go to pay for what we have, from government contributions using general tax revenue from the Federal, State and Local levels, the amount employers contribute, and the amount that individuals pay in the form of premiums, co-pays and deductibles.

Republican Lie #1

“Democrats just want free stuff!

Truth:  As I mentioned in the opening, there are a lot of different plans being proposed by Democrats, but no one is suggesting that it is just “free” (meaning paid for with tax dollars).  If there are Democratic candidates that are giving you that impression, they are doing a bad job of explaining it, or they are even trying to mislead you.  The reality is that the goal of the Democratic Party is to provide coverage for EVERYONE, and to do it more cost effectively than the current system, so that everyone can afford what they are being asked to pay.  The idea behind these different plans is not to give it away for free, but to make sure everyone has access to the care they need for a cost they can afford (and based on numbers I have compiled, it would cost less for anyone making less than about $350,000 a year and not increase government or corporate spending at all, while also not being completely free for anyone really, except children who are too young to have income).

Republican Lie #2

“Democrats just want rich people to pay for everything, and it’s not fair!  They want to punish success!

Truth:  Unfortunately, that does seem to be the rhetoric being thrown around by some candidates because they think it sounds good.  The reality is that there is no realistic plan that could be funded entirely by “rich people”.  Realistic plans are based on taking the overall cost of healthcare for every American and sharing that cost across the board, having what each person pays tied to their income so that everyone can afford it and everyone is contributing to it, and the government is not stuck footing the full bill, which we really cannot afford, but rather continuing to contribute roughly the same amount it does now.  For individuals, as stated above, it would cost everyone making less than about $350,000 annually less than what they pay now (somewhere around 3-4% of each person’s gross income), and even a wealthy person, making say $1 million annually would still only be paying around $30,000 total for healthcare, which is both affordable based on their income level, and only about $12,000 or so more than they are paying now (not enough to have any real impact on their quality of life, business or accumulation of wealth, and given that you can make a strong argument that without our health, nothing else really matters.  In my mind, that means EVERYONE must have access or we are failing as a nation, and no one should go bankrupt because they get sick, so even if you think this is unfair, I think it’s just something you’ll have to get over…just like you do with funding the military to protect us, the roads we drive on and an education system so we can compete with the world.

Now, to get into the actual discussion that prompted me to write this article, I have just copied and pasted the related comments from a much longer thread.

Also, please forgive the crudeness of this article from this point forward, but when I found myself engaged in a discussion about preferred Presidential candidates earlier today, I ended up going into some lengthy rants about healthcare in response to some of the comments by others.  Given all of the things we must consider as we head toward November, I wanted to capture it as a part of a real discussion because I think it really offers some insights into how people think about the issue and offers points that we should consider when we hear different candidates and the two main parties putting their rhetoric out there.

I will just say that it is all just off the cuff, but still accurate based on a considerable amount of research I have done on the subject over the past few years.  At the same time, maybe it will hit home a little more effectively because it is in the format that most people are used to when they are debating something on their own and not just some boring, lengthy research paper.

Two other comments, before you get to the actual discussion…First, I am not putting this out there to reflect negatively on anyone, but rather just to illustrate some of the commonly held views I see people offering up.  Secondly, there are a lot of different ways to skin the cat, meaning there are a lot of incremental steps between the system we have now, and what the best possible system could be if we were starting with a blank sheet of paper.  What my comments are in this discussion are looking at the issue as if we could start over from scratch and design a perfect system.  Obviously, no candidate is going to have the benefit of a fresh start, so while it may not be realistic in the short term, agreeing on the goal is probably the best place to start so that incremental progress can be made toward a real goal, and not just random changes that never seem to lead anywhere worthwhile.

So, with all of that said, here is the discussion as originally posted on Facebook (and I am only including the comments that involved healthcare since the debate was much broader than this one issue):

Original Posters Comment:

“I’ve been on the fence about which Democratic candidate to vote for in the primaries. Every one of them would be light years better than what we have now, and I’d vote for any of them.

But a comment I read yesterday about the Senate “trial” made up my mind. It said that the reason why the Republicans are going after Joe Biden the hardest is because he’s the candidate that they’re most scared of. And that there’s hardly a peep about Sanders because they WANT him to be the candidate.

This has made up my mind that Biden will get my vote.”

Person #2 Response:

Biden will get you the status quo. We need universal health care. Biden will cater to big pharma. Bernie will not. Biden thinks compromise. Bernie knows better. Voting for Bernie because he did not sit down and be quiet when trump took office. Where were the rest of them?

Person #3 Response:

Not that I don’t like universal healthcare, etc.  But he can’t possibly fulfill his promise. Deficit is sky high. Where is the money?  Then the idiots will just blame us.  Again.

Original Poster:

Most candidates agree that universal health care SAVES money.  But I’ll be satisfied if we can reverse Citizens United.

Person #4 Response:

How do we pay for never ending wars and tax cuts for the wealthy and billions in subsidies to profitable corporations?  But take care of citizens and suddenly everyone is fiscally responsible?  Please.

Person #5 Response:

Both Bernie’s home state of Vermont and California tried really hard to do universal healthcare and they both gave up!  How come?  Too expensive!  They’d have to dramatically raise taxes on EVERYONE not just ‘the rich.’  Notice that Bernie is always very vague on how he’d pay for it.  And be very aware that Bernie won’t get anything at all done unless he gets both the House and Senate on board.  Which he will never be able to do!  The presidency isn’t a dictatorship.  Look at how hard it was to get Obamacare done and it has still never been fully implemented and it looks like the repugs are about to finally kill it for good!

My Response to Person #5:

I have done some research into the whole universal healthcare issue, specifically the financial side of it, and without writing a dissertation here, the most sensible way to fund the whole thing includes, keeping the amount the federal and state governments currently pay into the multitude of existing healthcare programs, including Medicare, Medicaid, CHIP, etc, at the same level it is now. Add a business tax specifically for this which runs approximately 50% of what businesses overall spend currently on employer sponsored health insurance, so it is a net savings for businesses overall and affordable for smaller businesses that offer nothing to employees now. And then, finally, if you take the total adjusted gross income of all individual tax returns combined, it would cost individual taxpayers approximately a 3% flat tax of gross on all income, including both wages and things like capital gains. That 3% of gross tax would replace everything spent currently on premiums, co-pays, deductibles, and any other costs, so you would effectively never receive a medical bill for anything, just pay the 3% tax. Just using averages for what the typical American spends for healthcare annually (on average), it works out so that anyone earning less than $350,000 per year gross would pay less than they do now, and people over $350,000 would pay more for healthcare than they do now. Obviously, someone with no healthcare now, eve 3% of a $25,000 a year income would be an increase in what they pay, but they would be getting healthcare that they do not have now at an extremely affordable rate.

Bernie’s plan, from what I have seen is very similar, except he uses a progressive healthcare tax so instead of 3% across the board, he starts lower and I think ends up at around 4-5% on the richest Americans. Personally, I like the flat tax on this better (with no cap) because it seems as though this leaves everyone basically paying what they can and contributing to the system without putting an unfair burden on anyone.

Person #5 Responses:

Committing to fully implementing Obamacare would be a lot easier. Both Vermont and California tried really hard to do universal care and they finally gave ip because it was WAY too expensive!

Good luck with that. Bernie will never get the votes to radically change over to universal care. He’d need to get all three branches of government on board. Why not commit to fully implementing Obamacare with a public option?

My Response to Person #5:

I’m not saying he could accomplish it, but you were talking about the numbers, so that is what I responded to. Fully implementing the ACA (and undoing all of the GOP changes that have weakened it) would be an improvement, adding a public option would be an improvement above and beyond that, and if we could ever get to true single payer instead of all that, it would be the best option possible, because it is ultimately the lowest cost and covers every single person. Everything else between what we have had and the various upgrades you mentioned gets us closer to the optimum situation, but not all the way there.

In the end, there are two things that make true single payer the lowest cost and most comprehensive option for covering Americans, and they can’t be replicated with private insurance as a part of the equation, or by giving Americans a choice in what insurance program they run with.

1) The absolute lowest cost solution for providing any sort of “insurance” protection is to put together the largest risk pool possible, and there is no larger risk pool in America than if you throw all 330 million or so people into the same one. You spread the costs of healthcare out over the most people, and it creates a system with the lowest possible per capita cost.

2) You cut out the middle man by eliminating private insurance completely. It serves no purpose. In fact, by going to a true single payer system, you are effectively eliminating “insurance” all together. You are not paying premiums to cover possible losses later, which always include extra for a cushion to make sure that worst case scenarios are still covered. Instead, the single payer is just covering the actual costs as they come in, without a safety cushion (the overall liquidity of the government is the safety cushion instead) and without the profits paid to the middle man. The best examples of how this works for smaller groups every day in this country are some large corporations and labor unions that have the financial resources to self insure. That is exactly the same as what single payer would be, except because of the significantly larger risk pool than even those examples, there is far less risk and lower average cost per person.

One last thing that progressives do a TERRIBLE job of explaining, and way too many voters seem to misunderstand is the term “choice”. Opponents (including centrist Democrats) to single payer talk about how single payer takes away your choice, it takes away your existing healthcare, and similar comments like that. That is absolutely false! Now, I am not sure about how other people look at this, but as for me, I look at insurance as a necessary evil because that is the system we have. You rarely get much choice in what insurance you take, other than a maybe different deductible/premium combinations if your employer offers more than one. The ACA gives you the choice of a few different companies in most areas, but the plans are all very similar. And in both cases, often those “choices” are almost all HMO’s which in practice give you practically zero choice because you can only seek care “in network” and everything must be based off referrals by your primary care doctor. With single payer, you actually get the ultimate in “choice”…your healthcare is not tied to your job, so you are completely free to change jobs without giving a second thought to your healthcare because whatever you have set up travels with you, and does not get left behind with your employer. And then, as for the actual healthcare services, you choose any provider you want, not from a network that limits your options. If you need something, you can actually seek out the best possible provider to deal with your situation, the one who offers the services you need, the technology and approach you want, or whatever. It’s not bound by networks, geography, price, or anything…all your choice.

I would argue is is also the best solution for actual providers as well because it allows them to retain the profits themselves, and not have the insurance company skimming off the top. The single payer (government) would of course negotiate or dictate allowable rates, like is done with Medicare, but run properly, the private providers would receive a fair payment for services, know what it will be ahead of time as they choose what services to offer and how to offer them, and be able to structure their business model with a known revenue amount. That’s a far more predictable business model than what we have now, where the same service can generate revenues all over the map depending on which insurance the patient has.

Again, I have no real faith that this will be implemented, because there are too many people behind the scenes that would lose their gravy train and they will fight like hell to keep making obscene amounts of money for adding little to no value to the system, but if we can keep this as the goal, we can at least get closer than we are now.

Person #5 Response:

You forgot to mention that 80% of Americans already have private insurance or employer provided insurance and putting 80% of the American people on notice that their private insurance is going to be TAKEN AWAY FROM THEM and replaced with a government run plan is Political SUICIDE!!!

My Response to Person #5:

Let me start by saying I do not disagree with you. It would most likely be political suicide…but that’s not because it is a bad plan…it’s because in general, American voters across the board are dumbasses, and they consistently get pissed off and support things that are not in their own best interests.

So, why do I say Americans are generally dumbasses when it comes to healthcare? No, it is not because i like to call people names. It’s because of this:

Option A – Current system of mostly employer provided healthcare. That means the following:

1) You have no real choice in healthcare, neither with the insurance you have or the providers you go see. You are locked into only the choices your employer decides to offer, which is usually a very limited offering, and then once you choose your insurance plan, you are locked into only seeking treatment from the providers included in that network.

2) Once a year, your employer can very easily choose to change the insurance company they work with, so you are forced to change your entire list of doctors, which if you never see a doctor may not be a big deal, but for many, they have ongoing issues and changing doctors is a huge hassle, you start over because medical information in not broadly shared or accessible between different provider networks and you employer, depending on their financial performance can decide to no longer offer health insurance or change the amount they subsidize, causing unexpected increases in your cost.

3) You are not free to change jobs seeking one you like better or that offers better opportunities for advancement, higher wages, or whatever. You have to make your career decisions based in a significant part on the healthcare that is tied to a particular job. if you are laid off through no fault of your own, you lose your coverage (or try to pay for Cobra coverage, which is unaffordable for nearly everyone, particularly considering you just lost your job. If you voluntarily leave your job, you have to try to cover the cost of Cobra while you wait out the waiting period to start your next insurance plan, or you can roll the dice and go without for up to three months, even if you did not have a single day off from work during the transition.

4) Small businesses are hamstrung in pursuing quality employees unless they can offer the same kinds of health insurance plans that big companies offer, which they frequently cannot, particularly start-ups, and even if they can offer some type of insurance, employees are reluctant to change jobs because they will likely have to change insurance, doctors, etc. (and deal with the gap due to waiting periods, etc.)

5) Entrepreneurship, which is a huge engine of opportunity for people to improve their lot in life, leads to huge advances in our society and creates tons of jobs is restrained because even for the entrepreneur, they have to figure out how to provide for their own healthcare while they are trying to start their business. This limits everyone’s opportunities and basically, you ca have the greatest business idea on the planet and unless you have a spouse who works for someone and provides insurance coverage for you, you’ll never be able to make it happen.

6) Employers factor the cost of benefits they provide into their total payroll costs as a part of their business plan, so whatever insurance they offer, even if they pay 100% of the premium is in reality, coming straight out of YOUR earnings. They aren’t eating that cost themselves…it just seems like it to people who don’t think about it, so if healthcare premiums are say $500/month for an employee, that is $3/hour less that they will be paid and free to spend how they wish. If that is say a $40,000 a year full time job, that means you are losing $6,000 a year to cover the premiums your employer is “paying for”, or 15% of your income (for just the premium) versus 3 or 4% you would be dinged with single payer.

7) If you believe point #6, and I am not sure why you wouldn’t, then you will also be paying your co-pays, deductibles, etc., usually 20% of the total, up to whatever your max out of pocket is, frequently $5,000 to $10,000 a year for a couple without kids even, and that is after you cover the deductible. With single payer, other than the tax, you pay nothing more.

8) The private, employer based insurance system could care less what you earn. Whether you make $30,000 a year or $300,000 a year, your healthcare costs the same. Now, if you are wealthy, that may seem fair…everyone pay their own way. What that means in reality is that half of our population either has no healthcare, or can’t afford to use what they do, so now, you are paying a premium for insurance that will bankrupt you if you actually use it.

So, THAT is what people are pissed off they would lose…no choice, prices they can’t afford, and total restriction on how you choose to earn a living because work and health are tied together.

Or, you could go with Option B – Single Payer

1) Absolute lowest cost possible, and with that cost tied to your income, instead of your employer, meaning regardless of what you earn, or where you work, or even if you hit a speed bump in your career, you still have access to healthcare, and it is always going to cost you an amount you can actually afford relative to your income.

2) Absolute free choice on which providers you seek healthcare from. One system means every single provider is included in the system, and therefore, you can choose literally anyone you want to go to see. You can find a provider that is convenient, that you like, or that is the best at whatever specialty you need, and then if/when your situation changes (say you get cancer), you can find a different provider that specializes in the treatment you need because all doctors are not the same.

3) Your access to healthcare can never be taken away from you because of an employer’s business decision, because they go belly up, because you get fired or laid off, because your union decides to strike, or because you want to change jobs to find a better one. It also doesn’t go away because you get divorced and your spouse was providing your insurance, or for any other reason.

The problem with all of this, and why you are absolutely correct in saying pushing single payer is political suicide is because Americans are dumbasses…they don’t like change, even if it’s for the better, they don’t understand how the system really works because they have never thought about it (it just is what it is, so why think too much), and they have been purposely lied to and mislead for decades by the rhetoric of people who profit obscenely by maintaining the status quo (and people who just hate the idea of the government doing anything other than paying for the military.)  And the other problem is that even the politicians who try to push single payer do a HORRIBLE job of educating people about how much better it is.  Either they don’t understand it themselves, they don’t take the time, or they are just not as good at sales and marketing as the people who oppose single payer are.

Obviously, there is more to it than that, and like anything, the devil is in the details, but with all of the interest in the coming election, I just think it would be helpful if people started having conversations that were at least a little more accurate and factual, and if the candidates are not going to do a better job of explaining this issue and their proposed solutions to voters, then we need to start figuring it out on our own.

One thought on “2020: The Healthcare Debate”

  1. Great analysis. Universal single payer healthcare is the only thing that makes sense. It is way overdue and it is downright shocking that we still don’t have it.

    I think an important part to add to all this is taking away any non-negotiation laws. We should negotiate the heck out of drug prices, etc.

    Liked by 1 person

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