Questions for All - Medicare for All Primer for Journalists

Now that Kamala Harris, a top-tier Democratic candidate for President has announced her support for Sanders's Medicare for All plan, it's time for journalists to start asking tough, informed question. Because we all know how hard that is for them, here is a primer to get them started. Hopefully, they might use this to actually inform the public unlike what happened with Obamacare, where I defy you to identify a single story in the New York Times or on cable news that included the fact that about 1/3 of the uninsured at the time were illegal immigrants and 1/3 were eligible for Medicaid but had not enrolled. Of the latter group, it is almost certainly the case (but we will never know since the media didn't report on it), that these uninsured were healthy individuals who were reasonably waiting until they needed healthcare before enrolling. If Americans had known this ahead of time, then they wouldn't be surprised to find out that Obamacare has reduced the uninsurance rate by only 40-50%. But of course, that fact is barely mentioned these days either, and if so, it is assuredly blamed on the states that did not expand Medicaid.

Which leads into the first set of questions. First, "What problem(s) is Medicare for All supposed to solve?" For this, I have a suspected answer: to reduce the uninsured rate to zero and lower the costs. Any knowledgeable journalist or citizen should immediately remember that Obamacare was advertised as a solution to both problems. In the run-up to Obamacare's passage, not a single news story caveated that Obamacare would only reduce the uninsurance rate to 5-10%, not a single news story (from traditional sources) warned that Obamacare would not reduce costs, they instead repeated the administration's claims that it would lower costs. Remember, "bend the cost curve down"? The fact that the Democrats now want to fix both of these problems should be a constant reminder that Obamacare failed to solve these problems and not a single serious journalist warned Americans about these predictable shortcomings.

For specific questions, first, I want to congratulate Jake Tapper for asking a terrific question of Harris--is she in favor of completely eliminating private insurance. This is a clear outcome of the Sanders Medicare for All plan, but then, he is an avowed socialist. To which, at the risk of an over-abundance of praise, we should laud Senator Harris for replying that yes, she does want to eliminate private insurance. Her team tried to backtrack, and then later stood by her original statement. It's currently a little unclear as to what she thinks about private insurance, but we can be confident that this issue will come up again. This is the first question that should be asked of every candidate, "Do you want to, as the Sanders plan does, completely eliminate private insurance?"

Some follow up questions:

"Do you know how many people are employed directly or indirectly through the private insurance marketplace? What will happen to them? Does your plan include paying their unemployment and helping them find new jobs?"

"Will your plan do anything to make investors in these companies whole? How much money will investors, pension plans, and retirees lose from your nationalization of insurance?"

The second set of questions involves Medicare Advantage. President Obama and the Democrats tried to mortally wound Medicare Advantage by reducing payments to MA plans through the ACA, but it, to the surprise of everyone, grew after the passage of the ACA. For those who don't know, Medicare Advantage offers Medicare recipients a private option to compete with traditional Medicare. Approximately one third of eligible seniors choose an MA plan in lieu of traditional Medicare. As far as I know, the Medicare for All plans do not mention Medicare Advantage, but I would assume they want to do away with it. 

Questions:

"Will your plan, in addition to eliminating the current plans of the majority of working Americans also eliminate the plans of approximately 1/3 of seniors? If Medicare for All does not pass, do you still favor eliminating Medicare Advantage? Do you believe choice is good for consumers in general? What about the healthcare market makes choice a negative factor?"

These questions should be asked of the candidates, not because they're "gotcha" questions, because they aren't. They are serious and important questions that will matter to people. They impact a lot of people's lives and they show that the candidate has done her homework and is not just promising the moon. If journalists start doing their job and actually providing the public information, Americans can replace the epithets they currently hurl at each other with facts.

Dems ask Trump admin to keep young people's health costs high

From thehill.com (edited to show the perspective of a less powerful demographic group) 

Senate Democrats are urging the Trump administration not to move forward with changes to ObamaCare that could lead to increased healthcare costs for older Americans decreased healthcare costs for younger Americans.

In a letter to Tom Price, the newly confirmed secretary of the Department of Health and Human Services (HHS), Democratic Sens. Maggie Hassan (N.H.), Sherrod Brown (Ohio), Amy Klobuchar (Minn.) and Kirsten Gillibrand warn against adjusting the age rating requirement in ObamaCare.

The Huffington Post reported last week that a forthcoming HHS regulation could change the ratio set under ObamaCare on how much more insurers can charge older people than younger people.

“We write to express our serious concerns that the Trump administration is reportedly considering a change to the Affordable Care Act (ACA) that would have the direct impact of increasing health insurance costs for older adults decreasing health insurance costs for younger adults and ask that this policy be removed from consideration,” the senators wrote.

“We oppose rolling back consumer protections established in the ACA that protect older Americans from discrimination codify discrimination of younger Americans. Loosening the age rating requirements in the ACA without also expanding advance premium tax credits is a misguided policy that will make health insurance less affordable for millions of Americans more affordable for millions of Americans.”

Right now, the ratio is 3:1, meaning insurers can charge older people, who tend to have higher health costs, three times as much in premiums as younger people. Insurers have long been pushing to loosen up that requirement and allow for charging older people more while charging younger people less. 

The Huffington Post reported that the Trump administration is considering a regulation to change the ratio to 3.49:1, under the theory that 3.49 still “rounds down” to three and therefore follows the law. 

Republican-sponsored bills in the House would change the ratio to 5:1. 

“We are concerned that the reported proposal to relax the age band will amount to an insurance company give-away at the expense of older adults to the benefit of younger adults,” the senators said. 

AARP, the powerful seniors lobby, has threatened to sue the Trump administration if it follows through on the regulation.

Democrats Admit Actions Politically-Motivated

The news isn't that their actions are politically motivated. The news is that they admitted it.

Democrats continuously claim that their actions are noble--they're doing the best for the American people.  Those evil Republicans, however, always have nefarious political motivations. If you follow the news closely, you would have noticed how frequently they brought up Mitch McConnell saying his main goal was to defeat President Obama.

Well, here's Democrat James Clyburn admitting that they designed the ACA to help them win elections. Now Republicans have the opportunity to take the moral high ground. Why wasn't the sole goal of this legislation to insure the uninsured and bring costs down--to help people?  How many people have to go uninsured so that the Democrats can win in 2014? How many people are going to die for their blatant politicking?

I expect to hear next to nothing about this development from Republicans, from the media, and from the Democrats who endlessly criticized McConnell.

Bad Analogy II - Tom Toles

Ezra Klein thinks this Tom Toles cartoon is a perfect representation of what's going on with the Healthcare law.  Bad analogies strike again!

Democrats, on their own, passed the Health Care Law. The Republicans have done nothing to harm the operations of what was passed. What the Republicans have done is refused to fix some of the clear mistakes of the bill. Also, they have refused to provide more funding than what was allocated by the bill itself.

A better (more accurate, but still critical of Republicans) cartoon would have a large, complex machine in the background, spilling oil, belching out smoke, with screws falling out of it.  Problems that hinder but don't incapacitate.  A Donkey is looking at it through a window, banging on the wall with a wrench, while an Elephant is just staring at it saying, "This piece of junk will never work!"

The Objectives of Obamacare

Ezra Klein follows up on his post from yesterday with this one. In it he argues that no one to the right of Obama has suggested an alternative. But what he means to say, is that no one on the right has suggested an alternative that meets his objectives.

He describes Obamacare as "a policy to make sure most every legal resident of the United States has access to comprehensive, affordable health care. In order to achieve that goal, it helps poorer Americans pay for insurance and regulates the products offered by insurers to make sure they’re worth paying for." I imagine that's what he (and liberals) want any alternative to do.

The problem is that this is not how non-liberals would describe Obamacare, and though that may be the goal, Obamacare does so much more than that.  I think people of all philosophies can agree on a policy to make sure most every legal resident of the United States can afford basic healthcare.  The only difference with my wording and Ezra's is that I've reduced comprehensive to basic.  Of course, this goal had already been achieved before Obamacare since anyone can get treatment in an emergency room.  That's why the Republicans haven't really proposed much in the way of alternatives, because they believed this is the important objective, and it has already been achieved.

The difference, I suppose, is that Democrats wanted to exchange basic for comprehensive. Admittedly, I'm not really sure what comprehensive means. This was something lost in the debate, as happens. It's hard for people like me to argue when we don't know exactly what we're arguing about. I would welcome a debate as to what level of care everyone should have but they're not getting.

What I gather this means for liberals is that everyone should have access to an affordable insurance plan that covers preventative medicine and any reason you may want to go to the doctor. Now, if this is really the goal, then all that has to be done is give people the subsidy to afford it. That accomplishes the access goal. But, of course, that's not where the Democrats stopped. In addition, they had to mandate a whole slew of benefits that insurance had to cover and mandated how much insurance companies could charge. If the objective was just granting access, why are regulations necessary?

Because the objective is not "granting access," the objective is remaking the health insurance industry into an industry that liberals approve of.  That industry can't charge seniors more even though they're more costly, can't charge other groups more if they're more costly, can't spend too much on administrative costs. These are all bad practices.

So the goal wasn't only to provide access, but to root out distasteful practices.  To achieve the goal stated above should be relatively simple. All Republicans would need to propose would be to keep the subsidies and cut everything else. (Guaranteed Issue would also need to be addressed, and I think state pools or national pools expressly for the uninsurable is the way to go).

Liberal Debate Strategy: Appeal to Humanity

I challenge anyone to read this and not feel awful. Basically it's the story of how someone became sick, and his insurance wouldn't cover treatment without his challenging the CEO publicly.

I think anyone's first reaction is to feel miserable that anyone has to go through this. This is the emotional response.

Liberals are always, however, saying that they only look at facts/data. This clearly is not true. Sometimes they use examples like these to evoke a sympathetic response for their point of view. We must be cognizant of this strategy.

As far as data, one question I would have is whether this student had the option of another health insurance plan, and did he choose the cheaper plan. This is critical. If he chose the cheaper plan knowing of the limits and risks, then as tragic as this is, he made a choice.

I believe many liberals want to argue that this is not a choice people should be able to make (and they actually can't make it anymore under the ACA), but they must acknowledge that by restricting that choice, they're raising the costs of healthcare for everyone. If they announce that, and most people still desire this policy, great. But instead, they present this regulation as something that benefits everyone and has no costs.

Market-oriented people, if they want to argue for the ability to choose options that could possibly have tragic consequences, have to be ready to defend their stance against these emotional appeals, which is very challenging.

What's Good Enough for Them

In Friday's edition of Left, Right, and Center, the representative for the Left, Robert Scheer was asked whether Obama or Romney was helped by the Supreme Court decision.  Robert Scheer's response (presented as a question directed to Romney by Obama)

(starting at 16:30) What you did for Massachusetts I did for the rest of the country. How could you disagree with that? How can you call that socialized medicine? How can you say that's an unfair intrusion into people's lives? If it was good enough for the people of Massachusetts, why is it not good enough for the rest of the country? And I've extended it to 30 million people. I think that's an argument Romney loses. I don't even know what the answer is.

The Right's representative, John Eastman, gave a political answer: it raised taxes, it takes away freedom, etc. Maybe the philosophical response doesn't poll well, but I wanted to make sure that people realize that people like me have a much stronger answer to this question.

The answer is that the people in Massachusetts aren't necessarily representative of the people in the rest of the country.  Whatever is the best solution for Massachusetts may not be the best solution for the nation as a whole.  That's why people like me are strong advocates of federalism.  Letting each state find its own solution.  A national solution for a problem as complex as health care will never be as optimal as different solutions tailored to different populations of the country.

Simultaneously a Tax and Not a Tax

There are several aspects of the Supreme Court's decision on the ACA that still perplex me.

What exactly is the difference between a tax and a fine?
Don't taxes have to be paid before they can be challenged?
Don't taxes have to begin in the House of Representatives?
What is the explanation for the Medicaid decision?

I find reading the direct opinions can be very illuminating.  For example, I read the Conservative bloc's opinion, and came away with the realization that really they made a very strong case that Congress believed the mandate was not a tax, but not such a strong case, that it Constitutionally wasn't a tax.

Today, I think I can answer the second question.

This issue is discussed by Chief Justice Roberts on page 11 of his opinion (17 of the pdf)

It seems the answer to why this is not a tax for the purposes of the Anti-Injunction Act but is a tax for Constitutional Purposes is that the Anti-Injunction Act was written by Congress.  So it applies only to things that Congress thinks is a tax.

It would be like if you and I had different definitions for the same thing, say a computer.  Then I said I will buy you a computer.  Do you expect what you consider a computer, or do you expect that I give you my version of a computer.

Since Congress passed the Anti-Injunction Act, and said taxes must be paid before they can be challenged.  Then they wrote the ACA which calls it a "penalty," so the Anti-Injunction Act doesn't apply to it.  I'll try to think of an analogy to make this clear.

Insuring the Youth

Most of the people who doggedly follow health care reform know that one provision of the ACA forced insurance companies to allow young adults up to 26 to stay on their parents' insurance.  I find aspects of this bizarre.

First, it's probably the case that these people will have low health care costs.  Therefore, if they were participating in a perfect insurance market, the cost of insurance probably would have been low.  Why would it be in their interest to move to the parent's plan. Presumably, the cost of adding them to the parent's plan would be higher than the cost of individual care.  Therefore, they'd be subsidizing others.  Again, why is that in their interest?

Possible answers: parents would be paying, so it's cheaper for the children. But then, the parents could have paid anyway.  Still, I think that's the most likely explanation, as their are psychological reasons that'll push parents to pay when they're actually receiving the bill.

Secondly, why didn't the insurance companies do this in the first place?  If they weren't doing it before, that implies it wasn't in their interest.  But many companies have announced they'll maintain this policy even if the ACA is struck down.  What changed?  My best guess is that the insurance companies would have done this eventually, but the process was accelerated by the ACA.

Also, in this article at thehill.com, the author writes "Adding more young people to the insurance pool is popular in part because it helps lower premiums for everyone."  I think they meant to say "everyone else."  It costs more for the young people, of course.