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The battle over health care

Medicare-For-All Is Not Medicare, And Not Really For All. So What Does It Actually Mean?

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Sen. Bernie Sanders, I-Vt., center, accompanied by Sen. Kirsten Gillibrand, D-N.Y., center right, speaks at a news conference on Capitol Hill in Washington, Wednesday, Sept. 13, 2017, to unveil their Medicare for All legislation to reform health care. Photo: AP Photo/Andrew Harnik

Some candidates use Medicare-for-all to establish themselves as bold progressives or moderate pragmatists. The Trump administration uses it as a point of attack. But voters don’t know what it actually means, and none of the candidates explain it.

GAITHERSBURG, Md. — Ritchard Jenkins reached into the black computer bag he keeps near his workstation at Graceful Touch Barber and Beauty Salon and rifled through medical papers, pulling out an envelope buried deep at the bottom.

It was an unopened medical bill for $971.78, now 17 months overdue, that he had put out of sight and out of mind. Another unpaid bill from May for $447.13 rested in a nearby drawer. Both are the result of an arthritic knee that needs to be replaced and keeps the 55-year-old master barber in near-constant pain.

He makes numerous phone calls to doctors and insurance companies to discuss his coverage. And just when he thought he couldn’t take anymore, he fell down the steps, breaking his right wrist, tearing his rotator cuff and kickstarting a new round of hospital stays, tests — and insurance claims.

“Health care is ridiculous. These politicians really need to step their game up,” Jenkins said recently, using his left hand to hold clippers and a comb because his right remains swollen and partially immobile.

But Jenkins shrugged when asked if Medicare-for-all, the slogan that has dominated early campaigning in the 2020 Democratic primary, was the solution to his and America’s health care woes. He mumbled something about being too young for Medicare and laid bare the disconnect between how voters think and talk about health care and how candidates do.

As the Democratic primary campaign heats up, with the third debate scheduled for Sept. 12, candidates have used the slogan to distinguish themselves as bold progressives, moderate pragmatists or, in some instances, a little of both. The Trump administration has made it a point of attack, vowing to create a better system at lower costs. But interviews with voters and research by health policy experts show that the average voter has little idea of what is meant by the phrase that has already become a campaign signpost.

In its broadest terms, Medicare-for-all is what health care experts call single-payer: A system in which a government entity reimburses doctors and hospitals at a set rate. Many of the world’s most admired health care systems, from France to Israel to Canada, use some version of this approach.

Many health care experts argue that single-payer is the most effective way to deliver medical care to the greatest number of people. But until now, it has been politically unimaginable, taken off the table by most candidates seeking national office.

Health care “is the most important issue” of the election, and “single-payer is the right solution for American health care,” said Dr. Adam Gaffney, president of Physicians for a National Health Program and instructor at Harvard Medical School, who supports calling it Medicare-for-all but acknowledges pitfalls with the framing.

This “is an issue that affects, literally, every single person in this country,” he said. “Even putting the medical issues aside, it’s an economic issue. The way we finance health care promotes economic inequality.”

Medicare-for-all, in the purest sense, largely would replace private health insurance with a single, government-run program covering most everyone. It would be similar to traditional Medicare, the current federal health insurance program for most adults over 65 and young people meeting federal disability requirements, hence the name.

Sounds simple? It’s not.

Medicare was signed into law in 1965 after a 50-year effort to create a national health insurance system covering everyone. Opposition was so fierce that President Franklin Roosevelt excluded health insurance from the Social Security Act of 1935, and 13 years later President Harry S. Truman’s efforts to close what he called “the greatest gap in our social security structure” died in committee. The only way to get the law passed was by limiting coverage to older Americans.

And it’s worked, more or less, because of the government’s ability to set payments to health care providers. Still, high-quality, affordable coverage remains out of reach for many Americans, including many on Medicare. (Medicare covers only a portion of medical expenses, with many people buying supplemental plans to mitigate out-of-pocket costs.)

The Affordable Care Act, passed in 2010 during the Obama administration, was seen by many experts as a once-in-a-generation reform. Some argue it didn’t go far enough to provide every American with quality health insurance at a reasonable price. Others say it proves that the government isn’t the solution.

The fight over whether to expand the government’s health care system to cover all Americans has been part of the national conversation for generations, albeit often on the fringes, and was a topic of debate even before independent Sen. Bernie Sanders, of Vermont, made it his campaign rallying cry during his first Democratic primary presidential campaign in 2016.

In fact, it was the lessons learned during President Bill Clinton’s failed health care reforms in the 1990s that inspired the term Medicare-for-all. The phrase first appeared in the Congressional Record in 2003 on a House bill introduced by former Rep. John Conyers Jr., of Michigan, and again in 2006 when the late Massachusetts Sen. Edward M. Kennedy, long a proponent of national health insurance, introduced the “Medicare for All Act.”

But it was a former staffer who suggested Kennedy start saying Medicare-for-all instead of single-payer.

“It was too wonky, and no one knew what it meant,” Dr. Philip Caper, a single-payer advocate for nearly 50 years who worked with Kennedy from 1971 to 1976, said during a phone interview from his home in Maine. “I said: What we’re really talking about is expanding Medicare for everybody. I think you should use Medicare-for-all from now on. It’s harder to demonize it … and you don’t have to explain it.”

The senator took his advice, but the bill died in committee.

“This is the first time the notion of Medicare-for-all has really had any political traction” since 1974, Caper said.

It was the subject of the first question asked during the first night of the second Democratic presidential debate in Detroit, where the discussion lasted more than 20 minutes. And a recent Morning Consult/Politico poll showed that 65 percent of voters say they would support a candidate in the Democratic primary who favors Medicare-for-all over preserving and improving current health care laws.

Still, Caper said, for such a shift to work, there would be a huge need to educate the public and grow a large, active constituency around Medicare-for-all. Elected officials “hate the political pain” that often accompanies large-scale change, he said.

Plenty of people are arguing against Medicare-for-all, urging program reforms but not restructuring. Dozens of health care business groups created the Partnership for America’s Health Care Future to eschew “one-size-fits-all health care … whether it’s called Medicare for all, buy-in, or a public option.” And though the American Medical Association is not listed as a member on the alliance’s website, its president said recently that it too believes in a “pluralistic system.”

“Rather than disrupt what we have now, let’s build up on the progress of it,” said Dr. Patrice Harris, president of the AMA. “Ninety percent of folks have health insurance. It really is about the 10 percent of folks who don’t.”

Making national health insurance a reality would mean redesigning the country’s health care payment infrastructure. It would involve going from a diffuse network that includes private insurers for those who can afford it and public services for a limited number of those who can’t into a single government-administered system. The role of insurance companies would be vastly reduced. By one estimate, as many 2 million people who are paid to process insurance claims or argue about them would lose their jobs.

Would people get to keep their doctors? Unclear. Would prescription drug costs decrease? Uncertain. Would wait times increase? Unknown. Copays? No, depending on the plan. Increase in taxes? Almost certainly, but again, it depends.

Because the current system doesn’t cover everyone, the government would have to raise money (that is, taxes) to pay for a national health care system. Economists and health experts agree that this would cost significantly more than the $3.5 trillion the nation currently spends on health care, about a third of which is spent on private insurance. And a substantial sum of the nation’s health care costs goes to administering and processing insurance claims.

They disagree on who would get taxed or how much and over whether the trade-off — higher taxes in exchange for limited to no copays, premiums or deductibles — would be worth it. Some experts argue that creating a national health care system would cost the country an additional $32 trillion. Others say it would eventually save $12.5 trillion. Determining who’s right, and by how much, depends on the design of the system which remains a heavily debated point of contention.

“When you say Medicare-for-all, there are eight different flavors,” with each dependent on each presidential candidate’s platform, said John McDonough, a professor at Harvard’s T.H. Chan School of Public Health who was instrumental in both Massachusetts’ universal health care plan and the Affordable Care Act. “It’s an advertising slogan; it’s not a scientific concept.”

A Kaiser Family Foundation report from July found that about three-fourths of the country supports expanding public health insurance programs, including allowing those 55 to 64 to buy into Medicare.

But the report showed that how politicians talk about the issue matters, with 63 percent responding favorably to the terms “Medicare-for-all” and “universal health coverage.” Those positive feelings begin dissipating when it’s called a “single-payer national health insurance system,” dropping to 49 percent. They essentially evaporate if it means eliminating private insurance, increasing taxes or disrupting the current Medicare system, with about 60 percent opposing a national health care plan.

“The problem is: What is Medicare-for-all?” asked Ashley Kirzinger, associate director for the Kaiser Family Foundation’s public opinion and survey research team, which has been polling on the topic since Sanders’ 2016 campaign pushed it into the mainstream. “It’s not Medicare and lots of times it’s not for all, so it’s a little bit of a misnomer.”

Core dimensions of health policy — cost, access, quality and equity — vary wildly depending on factors such as income, geography, race, gender, ethnicity and job type, McDonough said, adding that creating a formula to improve everyone’s health care is “very hard. When you make changes, you will improve it for many but diminish it for others.”

All 20 Democratic candidates say health care is a human right, and universal coverage has been a cornerstone of the Democratic Party’s platform. But universal coverage and Medicare-for-all can be achieved in very different ways — one can include keeping private insurance and the other, in the strictest sense, doesn’t — and are not necessarily synonymous.

Candidates’ health care platforms exist on a spectrum from least to most disruptive, with some calling for building on the current system while others champion its complete dismantling.

Twelve support Medicare-for-all — or something like it — with some, such as Beto O’Rourke, the former Texas congressman, and Mayor Pete Buttigieg of South Bend, Indiana, opposing a single-payer system while trading in the brand recognition that is Medicare-for-all with their respective slogans “Medicare for America” and “Medicare for all who want it.”

The candidates’ views are not fixed. Some have occupied several positions at once or adjusted their plans to be more mainstream.

Three of the six senators in the race co-sponsored the bill written by Sanders to establish a national Medicare-for-all health insurance program. And until recently he remained the consistent single-payer stalwart, committed to the bill as written. But he, too, reportedly announced compromises for union workers that would allow any employer savings under Medicare-for-all to be passed along to workers in money or other benefits. Others, however, have flirted with — or flat-out embraced — maintaining private insurance.

And Sen. Kamala Harris of California, who calls her plan Medicare-for-all though it includes a mix of public and private insurance, co-sponsored the Sanders bill. She also co-sponsored four other bills along the ideological spectrum currently before Congress.

Then there are candidates such as former Vice President Joe Biden and former Maryland Rep. John Delaney who say Medicare-for-all is too controversial and costly an experiment. Universal coverage can be reached without completely upending the system, they contend.

Caper, the single-payer evangelist who helped popularize the term, said presidential candidates “water it down” and “confuse the issue” by suggesting Medicare-for-all can include commercial insurance.

To him it’s simple: The mission of commercial insurance is to make money while Medicare’s mission is to facilitate care for people. “That’s a fundamental difference,” he said.

Some voters remain unmoved, convinced that the health care debate is little more than meaningless campaign rhetoric.

“Politicians have no clue what it’s like out here,” said Margaret Coates, who, for more than two decades, worked in medical billing for providers and insurers.

Medicare is expensive and confusing, she said, and so is trying to buy health insurance. About two years before she turned 65, Coates said the government began inundating her with a dizzying array of information about Medicare.

“I did not know how expensive these plans were until I reached Medicare age,” she said, sitting in the magazine section of the Gaithersburg library, where signs posted against the back wall ask, “Are you eligible for help with Medicare costs?”

The need for help is widespread. Medicare covers about 80 percent of the costs of doctor visits and outpatient services; most seniors buy insurance to cover some or all of the remainder.

Coates’ 28-year-old daughter, a cosmetologist, has had her own health care struggles. Last year, she paid more in federal taxes for not having insurance, a penalty that costs at least about $700 per adult. (The Tax Cuts and Jobs Act of 2017 eliminated penalties for taxes filed in April 2020.) To avoid another penalty, she took on the cheapest insurance she could find at a cost of about $120 a month. With a $3,000 annual deductible, she has had to turn to her parents for help with medical bills.

“Everyone is up there cheering and happy because you have medical insurance,” Coates said. “But no one is saying what happens after you get it.”

Much of the conversation about the costs associated with Medicare-for-all include trillion-dollar figures, which does little to explain how it would affect taxpayers’ wallets. What resonates most with voters are not big aggregate numbers, but people’s out-of-pocket costs, said Kenneth Thorpe, an Emory University health policy researcher who worked as a legislative consultant to Vermont during its failed effort to create a single-payer system.

“We spent two years doing estimates, saying if we ran [health care] through the state, what would the state have to raise in taxes?” The answer, he said: Almost a 20 percent increase in payroll and income taxes. Creating a single-payer plan that would have covered everyone in Vermont would have forced some small businesses to close and put some people out of work.

In the end, he said the trade-off — increase taxes to expand coverage and decrease health care costs — wasn’t worth it, so “they dropped it, one of the most liberal states in the country.”

Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of the Medicare and Social Security programs said it would be an “analytical mistake to say we’re paying for this in other ways.” Because, he continued, “even if you make a very aggressive assumption for substantial administrative cost savings and substantial drug cost savings. It would still be the case that national spending would be higher.”

About 81 percent of Democrats and left-leaning independents say the federal government has a responsibility to ensure health insurance for all Americans, according to a recent Pew Research Center poll. The opposite is true of Republicans and right-leaning voters, 77 percent of whom say this is not the government’s responsibility.

Anger over the passage of the Affordable Care Act, which made health care more accessible and affordable for millions of Americans without coverage (though, critics say, not affordable and accessible enough), helped give rise to the Tea Party. Republicans made repealing President Barack Obama’s signature health care legislation central to their party’s effort until the 2018 midterm elections when voters turned out en masse demanding that key provisions be retained.

Still, the Trump administration said replacing the ACA is key, backing a federal lawsuit seeking to overturn the law and proposing rules allowing individuals to purchase short-term insurance, small businesses to join forces to offer employees health plans, and employers more flexibility in how they fund health insurance.

Health and Human Services Secretary Alex Azar reiterated the administration’s objective of “choice and competition” during a July speech before an advocacy group whose mission is to improve private health insurance options for Medicare beneficiaries while taking aim at the Medicare-for-all debate. He criticized “a total government takeover” as a “reckless” idea.

Taking a seat at an empty barber chair at Graceful Touch, Antonio Dickerson shakes his head in disgust at the idea of government working to improve life for people like him.

“Absolutely not,” said the 50-year-old, rubbing a scar on his shin, a reminder of health care interactions that have left him with a heavy dose of skepticism that Medicare-for-all — or essentially any government action — will result in meaningful reform.

He watched Jenkins, his friend and co-worker, return to work instead of recuperating after surgery because he can’t afford the supplemental coverage that would allow him to take more time to heal.

He watched his grandmother die two weeks after being released from the hospital, saying her insurer would no longer cover the cost of her care.

He watched one nurse’s shift end — and begin again — as he waited, uninsured, in an emergency room for hours, blood oozing from an open wound on his shin that eventually required 32 stitches.

“If you don’t have any money, get to the back to the line,” he said asking if those in the barbershop had ever seen “John Q,” a 2002 movie starring Denzel Washington about a husband and father whose son needs a life-saving operation but insurance won’t cover it.

Washington’s character takes the emergency room hostage, forcing the hospital and doctors to perform his son’s heart transplant.

That, said Dickerson, is “a very understandable situation.”

This article was originally published by ProPublica. ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

The battle over health care

Death by the Numbers: Region’s Grim Statistics Heighten Health Debate

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As Congress considers repealing the Affordable Care Act, health professionals in Kentucky, Ohio, and West Virginia grapple with what that might mean for a region where many depend on the law for access to care. This occasional series from the ReSource explores what’s ahead for the Ohio Valley after Obama Care. See more stories here >>

Eight protesters along a major thoroughfare in Lexington hoisted signs shaped like tombstones with sayings such as “RIP Trumpcare.” They were hoping Kentucky Gov. Matt Bevin and U.S. Rep. Andy Barr would catch a glimpse of the demonstration on their way to a press event at Valvoline headquarters down the road. Against the steady hum of streaming cars came a few honks. A middle-aged guy on a Harley gunned his bike through the intersection while laying on the horn.

“I don’t know if they are honking for us or if someone actually got in their way,” said Peter Wedlund, who is wearing a black Grim Reaper cloak.

Even in the very red Ohio Valley region a growing number of people are protesting the American Health Care Act, which would repeal and replace the Affordable Care Act, better known as Obamacare.

Some protesters who have long been in the trenches on the health care fight said they are newly motivated by some startling findings recently published in the Journal of the American Medical Association’s publication JAMA Internal Medicine.

That research grabbed headlines for its conclusions that in some parts of Kentucky, Ohio, and West Virginia people can now expect to live shorter lives than their parents did. This goes against the widespread trend of longer lives, and the grim mortality statistics put the stakes of the health debate in stark relief.

A Health Divide

Wedlund had concerns about healthcare in Kentucky before. The  JAMA statistics just confirmed his worst suspicions about how “Trumpcare” might play out in the region.

“The life span is going down. It is actually worst in Hal Rogers’ 5th District,” he said. Rogers’ district covers eastern and southeastern Kentucky.

Folks like Wedlund who’ve been following health policy knew instinctively what the statistics published by JAMA spotlight. Together, Kentucky, Ohio, and West Virginia lay claim to 27 of the 50 counties with the country’s worst trends in life spans. Of the 10 counties in the U.S. with the worst declines in life expectancy, eight are in Kentucky.

Rep. Barr’s 6th District includes two of those counties, Powell and Estill. Rep. Rogers’ district includes six of those counties – Breathit, Clay, Lee, Leslie, Owsley, and Powell. Owsley County leads the list with the worst change in life expectancy in the United States over the 35 years of data the JAMA study covered.

Wedlund and the others who staked out the corner of Blazer Parkway and Man o’ War Boulevard belong to Indivisible Bluegrass, which organized the protest via social media.

The national Indivisible group, according to its website, claims at least two grassroot groups in every congressional district and aims to “resist Trump’s agenda.”

Near Wedlund sat Susan Fister, who ran the Bluegrass Community Health Center in Lexington for decades. Its two clinics serve mostly poor people on Medicaid. Retired now, she’s worried that if approved the AHCA would require one of the clinics to close. The number of patients served and the number of employees would be cut in half.

She sat on a hot sidewalk with a sturdy black cane hanging over the arm of the kind of folding chair parents take to soccer games. A chronic illness makes moving difficult. She read from a sign propped in her lap.

“Valvoline provides jobs; Barr and Bevin provide misery. Stop the AHCA,” she said.

Susan Fister, who ran a federally qualified health center for years, came out to protest with other members of Indivisible Bluegrass (Photo: Mary Meehan / Ohio Valley ReSource)

Protests like these have popped up around the region for months as Congress debated and voted on repealing the ACA. Indivisible Bluegrass has been trying to track Barr, who represents Lexington and surrounding counties, at every public stop he makes in the district in May. About 100 people turned out to rally outside a private dinner Barr attended on the University of Kentucky campus.

The demonstrators see a disconnect between the region’s dire health statistics and the health care votes cast by their representatives in Congress. Of the 25 House members representing the Ohio Valley region, 17 voted for AHCA.

Opponents fear the bill will reduce health care access for the sickest and poorest in a region that benefited greatly from the ACA’s Medicaid expansion, and where high percentages of people have pre-existing health conditions.

Barr spokesman Rick VanMeter said that the congressman continues to support the health care bill. Barr explained his position in an interview with WEKU Content Director John Hingsbergen in early May.

“This is what the people of central Kentucky said, that they wanted us to repeal Obamacare. We’ve kept that promise,” Barr said. He called the day of the vote “a good day for the American people who are facing higher costs and fewer choices in their healthcare.”

Tough Choices

Hours after Fister and Indivisible took to the sidewalk, a political action committee called  the People’s Campaign set up in a hotel conference room across town. Minister L. Clark Williams of Shiloh Baptist Church said the campaign hopes to encourage candidates to run against incumbents and oppose the AHCA. They also are expressly looking for a candidate to challenge Barr. Williams said they are creating a network that includes Louisville and several counties in western Kentucky as well.

One of the speakers was Cara Stewart, a health policy lawyer and longtime advocate. She helped sign up thousands of people for Medicaid in Kentucky, something made possible under the ACA’s Medicaid expansion. Lately, she said, she’s felt physically ill from thinking about what will happen to the folks she promised would have health insurance.

She said some of the more dramatic aspects of the AHCA, such as the possibility that  pregnancy would be considered a pre-existing condition, are even hard for her to take in.

“Even when I hear myself talking, it seems so hyperbolic,” she said.

She said she sees grassroots protest efforts picking up momentum. She recently hosted an event where people filled out postcards to send to legislators decrying the AHCA. With just one day’s notice,  20 people showed up.

“We used all the postcards I had,” she said. Plus, someone brought money for stamps. “So that gives me hope.”

But as the bill moves to the Senate, she said, she fears many people might tune out from the health debate because it is so complicated and divisive.

“It’s so terrible that people do think it is dead on arrival,” in the Senate, she said. She thinks many are assuming that “there are too many reasonable people” for such a bill to pass. “But then, it passed the House,” she said.

Personal Experience 

Rev. Williams asked Colmon Elridge to come to the podium to share his story. Elridge worked closely with former Gov. Steve Beshear to expand Medicaid in Kentucky.

He is worried about what might happen in particularly poor areas, such as the 5th District, where analyses of the AHCA estimate 70,000 people could lose Medicaid. But Elridge also said the diseases most affecting people disregard borders. As the JAMA statistics show, he said, health care is a regional concern.

According to the Washington-based Center on Budget and Policy Priorities the AHCA would remove insurance from the 76,000 rural West Virginians who gained health coverage through Medicad expansion.

Policy Matters Ohio, a non-profit research institute, estimates that 700,000 people in the state will lose coverage if the Medicaid expansion is rolled back.

Elridge said he hopes voters understand the seriousness of the situation and how important it is to fight back. They elected people who promised to repeal Obamacare and it’s happening.

“Now that they know that these people are true to their word, we have to be true to our cause,” he said. Otherwise, he warned, “we are going to be to a place very quickly where people will die.”

Colmon Elridge, left, speaks with Nancy Jo Kemper, who ran against Andy Barr and lost, and Rep. George Brown, D-Lexington, right, at a meeting of the People’s Campaign. (Photo: Mary Meehan / Ohio Valley ReSource)

The AHCA as passed by the House addresses pre-existing conditions by creating what are called “high risk pools.” Health policy advocates say those pools have historically not been effective and that the current bill does not contain enough funding to provide adequate coverage.

The People’s Campaign event didn’t draw many people. The small crowd kept to the back rows. Williams wasn’t concerned. He said the intended audience is via Facebook Live. A tech guy squinted at his phone searching for bars as Elridge took the podium.

 

The story Elridge told shows the personal struggles behind the region’s mortality statistics.

At age 3, his father killed himself, a result of untreated mental illness. At age 14, Elridge recalled, his mother took to her bed for several days. The family first prayed, as they always did when anyone was sick, because they couldn’t afford a doctor. Then Elridge called the town veterinarian, the only doctor he knew. The vet told Elridge his mother had to go to the hospital.

She said no. They didn’t have the money. Finally, in defiance of his mother Elridge called an ambulance.

His mom survived.

After his speech, sitting in the hotel lounge, Elrdige said the idea that he could have lost his mother still affects him. What if he had made a different decision?

“I’m trying not to cry,” he said, not succeeding very well. After losing his father, he said, “I could not fathom losing another one. She had pneumonia. If I had just said ‘you’re right, Mom. I won’t call,’ and I buried my mother because of pneumonia?” he shakes his head in disbelief of that possibility.

He said he is fighting the AHCA because he doesn’t want anybody else to have to make a choice like that.

This story was originally produced by Ohio Valley ReSource.

 

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