Sunday, October 20, 2019

For the Record: M4A



I feel as if I may have been getting confusing lately on the subject of health care coverage, speaking positively about a "Medicare For All" model I've never liked that much, but then you have to ask, compared to what?

For instance, compared to the chaos that will commence if the Supreme Court finds for the plaintiff in Texas v. Azar (for which we should be getting a ruling from the Fifth Circuit Appeals Court sometime fairly soon) and the entire Affordable Care and Patient Protection Act is voided overnight, we won't have any ACA around to improve, and Medicare For All looks pretty good. Not that it's at all likely to happen. It would be a worse economic disruption than hard Brexit, and John Roberts wouldn't let it happen. And I don't think he could lay down some kind of structured settlement in which the ACA is gradually disassembled rather than being wiped out instantly; he'll just have to find it's constitutional, which is not that much of a stretch, because it clearly is constitutional.


Compared to the offerings of Democratic candidates who aren't in favor of M4A, beyond Tammy Baldwin's and Brian Schatz's "Medicaid Buy-In" which actually does look kind of practical except states will have to do all the work (Booker, Harris, Klobuchar, and Warren are all officially committed to this bill as senators but have not addressed it as candidates), there are Klobuchar's vague "public option", Buttigieg's superficially less vague but in reality even vaguer "some flavor of Medicare as a kind of public option for all who want it", Beto O'Rourke's Medicare for anybody, Joe Biden's "opt-in" and Julián Castro's "opt-out" programs for getting poor but not Medicaid-poor families into a Medicare-like program and allowing the less poor to buy in in some way don't seem at all well thought out. Kamala Harris has a concept that really deserves to be called "Medicare For All" because not only does it enroll everybody in Medicare (over a ten-year period instead of Sanders's four) but it gives us all 21st-century Medicare's most obnoxious feature, the planned inadequacy that forces people to sign up for private "Medicare Advantage" plans, which is Harris's plan for preserving the existence of the health insurance industry (and I know you hate it, but it's half a million jobs, many of them in California). And the hapless John Delaney preserves Medicare As We Know It by instituting a quite radical kind of Medicaid For All plan for everybody under 65, including actual Medicaid recipients, but only a "basic" plan which you'll want to supplement with an Advantage-type plan if you can afford it, which makes it sound as if he's actually trying to make things worse for genuinely poor people than they already are (Beto's plan looks like it has the same problem).

In that context, the official Sanders M4A, which I believe is pretty much the bill old John Dingell used to offer every year for five decades until his death in February, before the word "Medicare" existed, and his father before him going back to 1943, sounds at the very least like something real. And because it's a knowable quantity it's something that's going to be denounced by conservatives on really specious grounds, which is what I found myself dealing with today:





My own preference comes closest to Castro, really, but takes its formalisms right from the Affordable Care Act, with a bit of ideological overkill:
  • proclaim the principle of health care as an undiscussable human right;
  • raise the cutoff for Medicaid to somewhere around 200% of the poverty level (ideally calculated on a regional basis instead of one number for the whole country) and the cutoff for Obamacare subsidies to around 600%;
  • restore the "tax penalty" for failure to get health insurance, but as a percentage of income (above the Medicaid cutoff), and list it as a payroll tax;
  • create a federally backed no-profit "insurance company" providing equivalent benefits to Medicaid for all those paying the tax (those qualified are obviously paying a tax of zero, and and the undocumented are included as taxpayers) unless they are privately insured; and
  • do the real work to create no-profit entities in every state, Multi-State plans and co-ops, to compete with the existing companies and ultimately destroy them.
That's ensuring universal care by the shortest possible date, protecting the equity of the poor, and moving gradually toward a properly universal system without condemning people to suffer while it works itself out.

But please understand that "Medicare For All" is what we've got, at the moment, for what it's worth, from the candidates who have any clue at all what they're talking about, and (imprecisely) conveys what we all aim at, a system of health care provision without all this nonsense at the point of service, the interrogation, and the co-pay, and the OOPM.

For all I know, Warren's plan, in particular, the one that's generally been kept a secret from us, will turn out to be quite a bit like the one I like, because why wouldn't it?  I'd like everybody to not get too distracted, in the present instance, from the reality that whatever we do will be an improvement, and just keep pushing.


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