Medicare-For-All a Distant Hope
As we near the major phase of Obamacare’s implementation in 2014, there’s no shortage of carping critics from the right hell-bent on stymieing it at every turn. This despite early signs that it’s working to lower insurance premiums in states that have embraced it.
What does this political intransigence in the face of such healthcare reform evidence tell us? The obvious answer is that our politics trump consumer and patient interests, something I discuss further in Our Healthcare Sucks.
Given the history of the Republican Party as defender of suppliers rather than consumers, this isn’t exactly surprising. And given their antipathy toward President Obama, and Obamacare specifically, we can expect more of the same.
Obamacare’s repeal – which House Republicans have now voted for 39 times – is likely to be a central campaign theme for 2014′s Congressional elections. This will play to their electoral base, many of whom continue to indulge in imagined death-panel rhetoric to stoke fear among the politically naive (see “Obamacare ‘Death Panel’ Lies Must Die“).
But who’s playing to the base of those who support Obamacare – or better yet, those who favor a single-payer universal system like Medicare-For-All?
More Popular Than Obamacare
Public opinion polls conducted while Obamacare was being debated in Congress indicated greater public support for a universal healthcare system like Medicare-For-All that consumers in most other developed countries have long enjoyed – with lower costs and generally better treatment results to show for it.
The simplest and most effective solution for America’s medical access problem would be to expand Medicare to cover more people – Medicare-For-All. This more aggressive solution was actually supported at the time by almost two-thirds of Americans polled , and most doctors polled as well. 
Medicare-For-All would have solved the problem without inflating the coffers of a health insurance industry that adds little value, often evades payment for legitimate medical expenses, and adds an extra 20-30% to every healthcare dollar.
And Fairer for the Poor
Adopting a federal Medicare-For-All solution would also eliminate the disparities among states in access to healthcare, especially for the uninsured poor. This is seen most visibly in the divergent responses by states to the Supreme Court’s ruling that states can’t be penalized for refusing to comply with Obamacare’s intent to expand Medicaid to more of the uninsured.
Roughly half the states in America have either decided they won’t expand Medicaid or are leaning against doing so, as seen in a map from The Advisory Board Company – available here. This is occurring even though the federal government bears all of the incremental costs for the first three years and 90% thereafter.
Note that the states indicating they don’t intend to expand their Medicaid rolls are also those that filed suit to contest Obamacare – indicating the inherently political nature of these decisions that profoundly affect the lives of their poorest citizens.
Indeed, some states are rolling back their existing Medicaid coverage. This spiteful bit of political chicanery lays bare their cynical philosophy of governing for their political base and not their states’ entire citizenry.
The elephant’s “big tent” seems to be shrinking by the day.
the Only Serious Solution
In the face of such zealous political resistance, the powers-that-be in the Obama administration decided a single-payer Medicare-For-All solution – the only real solution to our medical spending crisis – was too politically risky, too easily demonized as “socialism”.
Of course, we now know that it didn’t matter what their plans for Obamacare actually entailed – they’d be demonized as socialized medicine in any event.
But their willingness to concede on Medicare-For-All before the battle even began speaks not to just their political miscalculation, but to their estimation of the public’s intelligence. Even a cynic in that regard, however, should have recognized it would have been easier to gain public support for a simpler Medicare-For-All plan that piggy-backed on public familiarity and comfort with Medicare.
And stronger public support for such a Medicare-For-All approach would likely have persuaded intransigent Democrats, and even a few Republicans, to cooperate in enacting a Medicare-For-All solution. Instead, public confusion about Obamacare, then and now, left a political vacuum too easily exploited by opponents intent on preserving the medical status quo.
Not Much Left Left
This refusal to embrace a Medicare-For-All solution to healthcare costs that continue to be the single biggest threat to our continuing financial viability and global leadership speaks also to the lack of a vibrant political constituency on the left of equal magnitude and intensity as that on the right. Despite the mass media’s stubborn reporting of false equivalencies between right and left, the truth is there isn’t much left left in America.
The agenda of the political left in America has devolved into defending the achievements of decades past against a Republican onslaught that can only be defined, honestly, as reactionary. Undoing programs like Medicare and Medicaid – and both are top Republican priorities, along with undoing Social Security – is, by definition, reactionary.
So, is a defense of decades of social progress the best one can hope for in the face of such an aggressive reactionary assault? And are watered-down advances like Obamacare – that build upon and reinforce market forces that undermine our existing healthcare infrastructure – all we can muster politically?
Is there no longer any merit in the adage that “the best defense is a good offense”? Congressional Republicans certainly seem to still believe in it, with gusto.
Defending the Indefensible
Amid charges that this is the most Do-Nothing Congress in recent memory, House Speaker John Boehner (R – Ohio) took to the airwaves this past Sunday to declare that “Congress ought to be judged on how many laws we repeal” rather than how many it enacts. Watch for yourself…
This creative interpretation of Congress’ role is supported nowhere in the Constitution Boehner’s party purports to hold sacrosanct. Nor is it supported by any of the implied powers that Congress derives from the Constitution’s Necessary and Proper Clause which permits Congress to “make all laws which shall be necessary and proper for carrying into execution the foregoing powers” described in the Constitution.
I suppose one can argue, as Boehner apparently is trying to do, that this implies unmaking any laws that aren’t necessary and proper for carrying out its Constitutionally-defined role. But making that the standard for judging Congress’ effectiveness seems a bit far-fetched – to put it mildly.
Yet this is how this Republican-controlled House of Representatives wishes to be judged. And notwithstanding its roots in Republican orthodoxy, the poster child for this repeal-obsessed Congress is Obamacare.
Imagine what lengths they’d go to with a more radical – and real – solution like Medicare-For-All.
Without Radical Surgery, This Patient Will Just Get Sicker
As a long-time fan of Robert Kuttner’s insightful commentary and analyses, I was briefly taken aback by his op-ed in the last edition of The Boston Sunday Globe (“A Sick System – Medicare ‘cost-savings’ rules are pushing costs onto patients”).
He starts out by recounting his 99-year-old mother’s hospital experience in which her 4-day hospital admission was categorized as an outpatient “observation” period that would have left her with a larger hospital bill had she no supplemental Medicare insurance coverage.
Having previously written about this very subject (see “Medicare Patients at Financial Risk as More Hospitals Game System“), it seemed to me that Mr. Kuttner was being overly-sympathetic to the hospitals he suggests are forced to comply with such Medicare-initiated billing arrangements.
Taken in isolation, that sympathy might be deserved. But in a context of broader patterns of deceptive hospital billing and collection practices and a continuing lack of billing transparency (see “Hospital Scams About To Explode” for more on this), it hardly seems deserved.
His broader point, however, is that Congressional efforts at cost containment in healthcare often amount to what he calls “gimmicks to shift costs to patients” and that what’s really needed is a more fundamental transition to a single-payer Medicare-For-All health insurance system.
And he’s certainly right about that.
He’s also right about the cynicism behind Congressional collusion with the “health industrial complex” in preventing Medicare from negotiating bulk discounts for pharmaceuticals purchased under Part D Medicare as enacted under the second Bush Administration. This is a perfect example of Republicans’ big government protectionism of private industry – in this case, the pharmaceutical industry.
Such industry protectionism, of course, interferes with fundamental free-market dynamics in which the largest customers get the biggest discounts. Apparently, this basic tenet of Republican free-market orthodoxy doesn’t apply when the taxpayer’s the customer.
So much for “free markets” in healthcare. And so much for Republicans’ purported opposition to raising taxes, since such industry subsidies are a hidden and substantial tax on the American people.
Kuttner also cites private insurers’ supplemental Medicare plans that target healthy seniors for maximum profits and so-called “consumer-directed” healthcare plans that combine tax-favored health savings accounts with high-deductible insurance plans as additional gifts to commercial healthcare players at the expense of Medicare and the taxpayers that fund it.
And the current Republican plan for Medicare vouchers would seal the deal by leaving poor and middle-income seniors without the insurance coverage they currently enjoy with traditional Medicare (see “Why is the AMA Trying to Kill Medicare?” for more).
This, too, would constitute an indirect tax by shifting currently tax-funded costs onto patients and consumers. And eliminating the price constraints that Medicare currently imposes would mean this hidden tax would skyrocket at a far greater pace than Medicare’s current spending trajectory.
All of these are ways to shift healthcare costs to consumers rather than finding ways to control those costs.
Whatever its shortcomings – and they are many – at least Obamacare is making an effort, weak-kneed as it is, to actually address the underlying costs of healthcare rather than simply shift them to consumers.
Unfortunately, without a substantial political constituency on the left to effectively advocate for Medicare-For-All, the odds are high that we’re in for more financial engineering gimmickry at patients’ expense.
 Public Opinion at the Time of the Vote on Health Care Reform. N Engl J Med. Published online @ www.nejm.org, 4/7/10.
 Doctors on Coverage – Physicians’ Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med. 9/14/09.