I agree with you and Emanuel. I like Michael Bennett for that reason. I want to heal America, not destroy it by rhetoric and unreasonable public policy. It may be true that single payer health insurance is the most efficient system but running on that ticket, IMHO, will ensure Trump's re-election. Healthcare for all: yes. One person, one vote and every vote secured and counted: yes. Repair the tax system: yes.

If you've ever had coverage cancelled, especially for a reason that seems contrived, and found that no new coverage was available at any cost, you probably feel that coverage is more fundamental than cost. I'm reminded of Donna Dubinsky's experience: Web Link

I've been down that path, without coverage and without any option to acquire it. The ACA made all the difference for me.

It's understandable that most people feel cost is the primary concern, *because they already have adequate coverage*. What most don't appreciate is how quickly coverage can be downgraded or eliminated at the discretion of their employers or insurers, and how likely that is to happen.

So, I suspect the candidates are generally on the right track. Coverage comes first, and the mechanism by which coverage is provided determines which cost-saving measures can be used. I'd prefer to see the candidates talk more about that issue (as a way of explaining why they prefer one mechanism over others), but a debate is a poor forum for that sort of wonky discussion.

Healthcare costs mean absolutely nothing if coverage is cancelled or denied. Healthcare is a fundamental human right in any advanced society except in the USA. Once lifetime coverage for every citizen and lawful resident is guaranteed, we can discuss lower costs, efficiency, etc.

Wasn't one of ACA's aim to reduce costs via increasing access (greater insurance pool...) ?

There is almost universal acceptance and support for public schools (free and open to all) .... why all that reluctance to public healthcare?

@Steve Levy,
For once we agree about something. Single-payer healthcare in this country is too easy a political target. I have spoken with Democrats in local party politics who have told me that they have given up pushing for anything more complex than single payer because Republicans will just attack it. (Hello! Republicans are going to attack ANYTHING. Democrats need to learn how to start honing their speaking skills and defending what's right. Sheesh!)

We do need to start differentiating health CARE from health INSURANCE. Around the world, every advanced nation on the planet has found some way to offer universal, low-cost health CARE. But not all of them do it through single payer. I am surprised by how many people do not know that even after you tell them again and again.

In fact, the economies most like ours use private insurers, but they are all non-profit. Our country is the last advanced nation on the planet that allows profiteering in health INSURANCE. The reason profit in health insurance is fundamentally in conflict with paying for people's healthcare is that profitmaking insurance companies have a responsibility to investors to maximize profits, which are a percentage of the overall healthcare economy. This means their incentive is to keep the overall healthcare economy HIGH (expensive) while maximally extracting their profits through control (hence the denials, which people mistake for cost cutting). This is why we have such outrageous administrative costs, amounting to about a third of every healthcare dollar.

Having choice in health CARE is actually important quality control. I do not think we can have a stable system that does not allow at least as much or more choice in care as we have now. Choice in CARE does not have to mean a more expensive system -- we already have as expensive a system as is possible for the insurers to maintain, it doesn't cover everyone, and it costs twice as much per capita as the next most expensive system with lesser outcomes.

In fact, this TED TALK is really important to listen to, because when the issue was systematically studied globally, they found that the best outcomes, according to patients, turned out also to be the cheapest (not the most expensive). Web Link

In addition, doctors getting practice getting the best outcomes also leads to a snowball of better care and innovation. Steve Jobs, for all his billions, couldn't buy his 55th birthday. If thousands more had been able to get the best care for the same problem before him, perhaps he would have.

Having choice in NON-PROFIT insurers can even be good, since most people work for a salary and if their company doesn't do a good job for people, then they could go out of business. But the only way to make those companies work to provide great healthcare for the least amount of money is to make them all non-profit insurers like the rest of the world has done. No conflict with paying investors. It's just about eliminating health insurance as an investment vehicle. Otherwise, the incentives are all wrong. That also happens to be the least disruptive thing anyone could do to the system. Just that one thing. It doesn't affect care at all, except to bring down the cost and maybe even make it possible to pay for out of pocket like many other advanced nations.

I predicted to my Members of Congress that the ACA would result in skyrocketing drug prices, because it was the easiest way for insurers to keep the overall size of the healthcare economy high while they figured out what to do next to keep profits up when governments caught on and finally put the lid on drug prices.

We do have non-profit insurers, but as long as they have to compete with for-profit insurers, they all pretty much act like the for-profits. Switzerland tried allowing its health insurers to make a profit in the '90s for healthcare, and not surprisingly, costs went through the roof, people started going bankrupt on health costs, so they held a referendum and reversed insurance profiteering, and not surprisingly, things settled back down. Our own system was much cheaper before we allowed for-profit insurers to dominate. (By the way, I am not talking about for-profit supplemental insurance, which many of the countries allow. It's the main coverage where you just can't have both for-profit insurance AND low-cost, high-quality, universal healthcare. They are fundamentally incompatible.)

Obama blew it trying to appease the insurers and allowing them to still profit. He needed a big win so people could see that our nation can do what all the others have done. Voters blew it by not having his back at the midterms, so what did they expect.

Anyway, I too agree that Democrats are blowing it by thinking that Medicare for all is the way to go. It's just, they think it's better than learning how to do a better job making their case than Republicans (who will say anything to keep power).

I think health care coverage and costs are both important topics.

But I do think many more people are affected by high and increasing costs than the number who lack coverage. Our son and his family have great coverage through Covered California. But they face mind numbing high deductible requirements as well as high premiums. I understand (readers can weigh in here) that employer based coverage has seen rate increases and also a higher contribution rate for employees.

So I do think in terms of the politics that reducing costs should be an important Democratic message and will resonate with many middle income voters.

On the health care practice/cost relationship (I invite health care experts to weigh in) I hope we reduce health care practices that increase costs and work on reimbursement schemes.

Emmanuel suggests moving away from fee for service reimbursement models and I agree.

We can also change rules that allow more services to be delivered by nurse practioners and nurses. We can expand urgent care and community clinics. Probably telemedicine has a role in reducing costs.

All of these changes could help reduce very expensive and often improperly used emergency rooms.

@ stephen levy,
Healthcare is a complex topic and everyone has different experiences and knowledge that they bring to the table. I would just invite you to dig a little deeper and re-read my post. One of the biggest problems with healthcare is the way bills are settled is for the benefit of the insurers (and their profit-extracting control of the system). Imagine we bought cars but were not allowed to know what we would be on the hook for until after we drove the non-returnable car off the lot. The car buying economy would be messed up, too. People should just be covered, and when it's care outside the norm for one reason or other but the doctor feels it's medically necessary (or potentially helpful for something rare), there should even be a way for people to be covered if their doctor documents their care and outcome well for a large evidence-based database. This would make healthcare and research dollars do double duty.

Naturally reducing costs is an important issue for Democrats, but those who benefit from keeping the system costly have spread a false framing for so long that it's not possible to save costs without reducing quality. This is the lie that keeps us from learning what we can do from the rest of the world who have achieved better healthcare for everyone for less (without necessarily using single payer to do it).

I think Democrats really need to take on the bigger issue of actually being far better stewards of the economy and democracy than Republicans, more fiscally RESPONSIBLE (fiscally "conservative" meaning the opposite all too often in recent years), more prudent about investments. That's why I think Obama really blew it with the healthcare reform by leaving insurance companies to make a profit. If we had completely reformed INSURANCE, things would have changed much faster, and Democrats would have shown how much better their approach is. As it is, it's still not an easy win, and people are still susceptible to believing we can't provide better coverage for a lot less money despite the fact that pretty much every economy like ours in the world already does.

I agree with the posters - start with access and then work on costs.

Take the republican party, for example: they seek to restrict healthcare access (repeal the ACA) while increasing costs.

They shouted 'repeal and replace' yet offered no replacement.

I'm speaking as one who will be uninsured if the gop had their way (pre-existing conditions) and have several in extended family or circle of acquaintances who would either be tossed off their plans, denied access or have reached the various caps that were removed with ObamaCare.

Since half my world happens to be 'of the feminine persuasion' , they would face increased difficulties with the pre-existing condition of being, ya know, female.

Personally, I'm okay with only a single payer solution, as it will dramatically lower our nation's healthcare overhead costs quickly. A friend explained the 3 basic healthcare systems to me this way:


1. For-profit insurance - 30+% overhead. Someone's got to pay those $100 million executive packages, gold plated executive washrooms, personal jets and the buildings of people devoted to denying their client coverage. And mail the endless forms.

How's that working out for you? Love your insurance comapany, do ya?

See also: gop governor Rick Scott and his company that paid billion dollar fines for defrauding the United States and ripping off tax dollars.


2. Single payer, ex: Medicare - less than 5% overhead. Go ahead, gop, tell the voters how you deep-down want to cut Medicare as you run up the deficit. Let's see how that goes.


3. Socialized medicine, best example in the USA is the VA system - 1-2% overhead. No one is denied (unless the system is underfunded by the gop.) All records and doctors in the same system, etc..


Every major country in the world gets better results at lower costs than America.

Portion deleted

@any plan,
That's an interesting categorization, but your analysis is far too restrictive.

For example, Germany uses private insurers, and people have choice -- they even have for-profit doctors, hospitals, and labs -- they just don't have any FOR-PROFIT INSURERS. Consequently, as this NY Times article points out

"“One can have choice without costly complexity," said Barak Richman, a co-author of the JAMA study and a professor of law at Duke. “Switzerland and Germany, for example, have lower administrative costs than the U.S. but exhibit a robust choice of health insurers."
Web Link

Swizerland is an interesting case because the country is very expensive and their insurance often covers the cost of recovering from surgery in a spa in the mountains. Yet still they pay less per capita than us and have no medical bankruptices.


Single payer is too easy of a target in our country. We want high quality healthcare for all, cheaper and better than we have now, with choice. The salient change to achieve that is to simply make non-profit only insurance nationally, no more for-profit insurance. That's it. The Blues were converted to for profit entities, they can be converted back.

As a retired person I went from a great healthcare/insurance situation through my employer to this Medicare deduction from my social security check which has to be offset by medigap insurance. Since this is a local discussion we could use some input from the PAMF/Sutter and Stanford Hospitals and medical services. The type of care provided suddenly changes since "once a year" visits have a dictated cost and the doctors are now limited in what they can charge. And every action required has to be evaluated as to what medicare will cover vs the individual. Government interferences in this whole process has not been any great boon - rather a hinderance to getting things done in a practical and efficient manner. What is worse your zip code also determines what is deducted for Medicare. They want to know what county you live in. We live in a very expensive county which is expected to offset the costs in lower value counties.

On the bigger scale Sutter and SU are building more hospitals and medical centers. Those are not going to survive if they are limited in what is charged for services to some government standard.

The D's are promising something which in fact will be a total collapse in the tangent we are now on, good or bad. And our local medical centers will be the end butt of the collapse. We need input from them on what this means to our ability to get good care.

I think insurance waste is part of the cost problem but by no means the major part or anywhere near a comprehensive solution.

With regard to a Medicare model and cost (I am a Medicare recipient) there are two problems.

One, as Emmanuel said is that traditional Medicare is a fee for service system, which, compounded by the problem of defensive medicine, leads to over utilization.

Second [Web Link web link] there are questions as to whether Medicare pays for non cost effective practices.

And insurance reform does not provide more community clinics, more primary and elder care physicians, more utilization of nurses and nurse practioners, more physicians willing to accept Medicaid patients and any practice reforms.

Third, there is another important meaning to access beyond whether one has coverage. Access includes effective coverage--are there practioners and clinics near you--maybe not a problem here but in many less urban places--can you get an appointment in a timely manner (critical for reducing inefficient and costly use of emergency rooms.

Cost and access ARE complicated issues and tirades against insurance companies ignore these complexities and related issues.

> The D's are promising something which in fact will be a total collapse

Interesting. Two questions:

1. didn't you say that about ObamaCare?

2. How so, and given the range of D plans, are you referring to all of them, or just a generic plan in your own imagination?

I can't talk to Obamacare since I have been on a company insurance plan and still am as they are great supporters of their retired employees. However they did have to provide a form for tax purposes to state that I was covered and paying into a system.
If I did not have that form then they would have charged me for no insurance as a penalty and you can agree that since that whole plan is dictated by your zip code it would have been on the high end. So that is the problem with Obamacare that got eliminated - penalizing people who did not have a health care plan. And since CA has a high number of people in the poverty category one wonders how they would have paid in or got penalized because they did not have a plan. As you now see more homeless people one wonders how that whole scheme would work out. Sorry that was a very punitive plan that thankfully I did not have to deal with. And since the D's are not going to win in 2020 then I am good to go with my company plan.

> I can't talk to Obamacare
> one wonders how they would have paid in or got penalized

No need to wonder - it's all written out in the plan. Been the law for years. Do you favor repeal?


> The D's are promising something which in fact will be a total collapse

2. How so, and given the range of D plans, are you referring to all of them, or just a generic plan in your own imagination?

All this is probably mute as it appears that DT is likely to win a second term and the House may well revert to GOP hands and the Senate stay as is. Not to my liking, but watching the debates and Democratic candidates it is hard to feature any of them except Biden giving Trump much of a run and all the infighting on the Dem side is just making it worse. Today's NY Times indicates millions of voters who did not like Trump in 2016 now say they like him, plus it looks like he is getting a bigger advantage in the Electoral College than he had last time-and that is what counts.

So we can all probably kiss any useful health care reform or improvement goodby for the next couple of decades at least. None of the party's will have sufficient advantage in Congress to pass anything meaningful, but they can swing repeals.

Most of the people that were employed by large companies did not get affected by Obamacare. The large companies are sailing along with private insurance. As to what ever the D's are suppose to come up with they cannot agree on anything.

Medicare for all is a giant loser - most hospitals cannot run on a pure Medicare pricing scheme. We had a situation in the county in which a number of Catholic hospitals went bankrupt and were sold. The state AG got involved with that and tried to prevent other hospital groups buying the beleaguered hospitals. That was an interesting situation as it told a very strange story as to intent. Luckily the hospital group counter sued and now those hospitals are open and active to support the local communities. There is more to this story as to involvement with how hospitals are run by religious groups.

> as it appears that DT is likely to win a second term and the House may well revert to GOP hands and the Senate stay as is

Uh-huh. What is that opinion based upon? Trump's 2018 loss of the House?

His record low job approvals or favorability, both not only low but stuck in a narrow band with little improvement?

Senate: Republicans will be defending 22 seats, the Democratic Party will be defending 12 seats - it will not "stay as is"

House: almost a dozen GOP house members have quit in the last TWO WEEKS. Why? They know they won't be in the majority for years. Democrats took over ORANGE COUNTY - you think the GOP is taking it back?

> it looks like he is getting a bigger advantage in the Electoral College

Based on what? He won 3 key states by less than 80k votes, total. The only way he is getting a bigger advantage in the EC is with massive outside help.

Just remember: any plan is better than the gop repeal. They never came up with a replacement as they promised.

> people that were employed by large companies did not get affected by Obamacare

Perhaps you missed the newspaper that day.

- Prohibit lifetime monetary caps on insurance coverage and limit the use of annual caps.
- Prohibit insurance plans from excluding coverage for children with preexisting conditions.
- Prohibit insurance plans from cancelling (rescinding) coverage
- Establish state-based rate reviews for “unreasonable" insurance premium increases.
- Establish an office of health insurance consumer assistance or an ombudsman program.
- Establish the share of premiums dedicated to medical services (minimum medical loss ratios).
- Requires insurance plans issued after March 23, 2010, to cover certain preventive care without cost-sharing, such as immunizations; preventive care for children; and specified screening for certain adults for conditions such as high blood pressure, high cholesterol, diabetes and cancer.
- Establishes a federal home-visiting initiative to help states foster health and well-being for children and families who live in at-risk communities.
- Requires restaurant chains with 20 or more locations to label menus with calorie information and to provide other information, upon request, such as fat and sodium content.
- Comparative research to study the effectiveness of various medical treatments
- Demonstration projects to develop medical malpractice alternatives and reduce medical errors
- Demonstration projects to develop payment mechanisms to improve efficiency and results
- Investments in health information technology
- Improvements in care coordination between Medicare and Medicaid for patients who qualify for both;
- Options for states to create “health homes" for Medicaid enrollees with multiple chronic conditions to improve care; and
- Data collection and reporting mechanisms to address health disparities among populations based on ethnicity, geographic location, gender, disability status and language.

The last group helps parents of "people that were employed by large companies". Surely you agree that helps such "people that were employed by large companies"?

We could fill up a couple pages with summaries of Wellness programs, further assistance to the families of "Health Workforce Development", Health Workforce Development, which helps all, etc..

Would you like me to send you some newspapers from the last decade to get you caught up?


...


Also: "people that were employed by large companies" includes the largest employers in America (ie.. WalMart.) Shall we list all the provisions to assist them?

Search "ACA and Medicaid", because so many of these companies fail to offer sufficient healthcare to all their employees.

Happy to help.

I suspect that just about every real citizen will eventually be covered by new forms of medicare administered by new joint public private agencies. Patchwork experiments from clinics to for-profit hospitals have gone on for years producing galloping costs for patients and large profits for low value entities such as insurance companies. Treatment can be great but overall the system is broken with, among other issues, unsustainable costs.
I fully agree with the author's four points.
Critics of medicare-for-all reject the option thinking moving everyone at once would, of course, be a disaster. But, it's possible to work towards that option over time. The menu of services the plan offered would be limited by the amount budgeted. The new agency, managed by professionals dedicated to high quality service and r&d, as improvements in technology and management reduces costs. As the budget allows, more items are covered. In the meantime, people also carry gap insurance offered by private agencies. Localities or counties for example could offer gap insurance subsidies for the poor as their budgets allow.
The net gain is a unified system of standard treatments always improving based on outcomes and a significant improvement in information management.
We are paying for health care now in a bizarre system of accounting that hides costs, pads bill, encourages fraud and requires far too much anxieties for everyone. To get sick is still a financial nightmare for many.
Obamacare, however well intentioned, overall was a dumb idea. We should move on. A new approach could be implemented in stages and very thoughtfully established. The effort by Bezos, Buffett, and Dimon to rethink how better and cheaper can be achieved to the very best advantage of the patient could be instructive.
Unfortunately, our politicians have not led in this - a big problem for the country getting worse and no matter how important the mudslinging and food fights in Washington may seem to them, this is an area that could actually benefit from our politicians getting down to work. So many of the problems mentioned here by others are due to a massive jumble of piecemeal solutions - evolving towards a good national model is our best option.

I have deleted some recent posts as they were disrespectful and off topic though the posters might want to start a thread of their own.

Each deleted post(er) has several existing posts left on the thread.

Let's make room for others to join a discussion of the issues raised in the blog.

P.S.
I'm happy to be a Republican and will vote to re-elect Trump AND I believe in moving towards a medicare-for-all model. While I don't believe healthcare for all is a right it certainly is good policy to have healthy citizens. Democrats do not have a monopoly on caring or compassion and Republicans are not a monolithic party of hateful, white supremicists. Those charges and constant labeling is not very useful and getting tiresome. This problem should not be partisan. The Dems now have the house but there is no plan from them either.

Some interesting posts here, but, I believe that many of the posters are making a serious implicit error regarding health care "costs". Please read the following article, which articulates the situation quite clearly:

Web Link

The gap between the -actual cost of care-, the payment that insurance companies make, and, the "bill" price, can be, and usually is, vast. In the article, it is the difference between approximately $60,000 cost of actual treatment for Wanda Wickizer (nobody knows or is willing to admit anyway the precise sum), the $60,000-$70,000 some insurance would pay, and, the $356,884.42 or $285,507.58 that she "owed". There is no standard markup and no transparency. IMHO, the situation is immoral and shameful, but, the hospital sees it differently:

"But the hospital did not accept any of the offers. In a letter, Peter Hetzel, an attorney at the firm, said his client would accept only just over $225,000, saying the University of Virginia Medical Center was “the victim here." He noted, too, that the small rental property that Wickizer owned �" appraised at $90,200 in 2014 �" was considered fair game for the hospital to seize as payment. "

> will vote to re-elect Trump AND I believe in moving towards a medicare-for-all model.

What is the republican plan? Literally, all I've heard is 'repeal and replace' with zero information about 'replace'. Two years of complete control, and they never offered replacement.



> The Dems now have the house but there is no plan from them either.

Incorrect: Majority of House Democrats Have Signed on to H.R.1384 - Medicare for All

"Cosponsors: H.R.1384" 116th Congress (2019-2020)
Cosponsor statistics: 117 current - includes 106 original"



So, what GOP health plan has *any* co-sponsors?

@‘any plan....' - A slogan is not a plan. The eventual solution will be incremental, evolutionary, occur at many levels in both the private sector and public and require everyone to pitch in. Most people would accept slightly higher withholding if needed in exchange for lifetime assurances that healthcare is available for all. In the long run, I think the private sector innovates better medicines, etc. to lower costs. My outline is not a plan either but a preference for what it becomes. It's likely a hundred pieces of legislation not one.
I don't see a Republican plan either and while that's disappointing, in general, I see Republicans as less reckless, more responsible. But, not to be misunderstood, I would hope it's both sides and the middle working towards a solution.

> I don't see a Republican plan either (but somehow) I see Republicans as less reckless, more responsible.

Okay.

Reality: The ACA *was* the republican plan, birthed by Heritage, raised through infancy by Mitt in Massachusetts, and co-opted by Obama under the mistaken notion that keeping for-profit insurance companies would get GOP support.

Appreciate the comments. We differ in that I see a majority of one party moving towards better coverage and outcomes, while the other party as doing nothing but 'repeal', is "a big (insert Biden euphemism here) deal."

Given the last election in 2018 and it's healthcare focus, a lot of folks seem to agree.

I'm a little slow, so it really helps me to appreciate good faith debate by identifying where a poster is 'coming from' relative to actual history and current events.

@any plan....

I think if we're all honest and objective, it's truly due to the extreme dysfunction of our United States Congress for decades now that we've been unable to solve this massive cluster of chronic dysfunctions called “healthcare" in our USA. This problem is owned by everyone, especially our Congress (both Ds and Rs), as well as the providers, hospitals, insurance companies, State governments, etc.

I agree with George on all points, and also am a big Trump supporter. I definitely think the Republicans are more responsible fiscally, socially and politically. If the Ds weren't wasting massive amounts of time and money on extreme 21st Century McCarthyism, irresponsible investigations, obsessing over race based politics, and overall hysteria, we might have been able to get something done.

Obamacare was just another cluster of dysfunction thrown into the existing cataclysm. It solved nothing with its airy fairy “oh let's just promise everything to everyone, figure out later how to pay for it, pass the hot potato to the states, and we'll be long gone...."

I agree with George on all points. I also happen to be a long time loyal Republican and Trump supporter. I've always believed the Rs are more responsible fiscally, socially and politically. If the Ds hadn't spent so much time on fomenting extreme, divisive and harmful politics, we might have been able to make some progress on this. What a massive waste of time and money they cause. The D sponsored bill referenced above is not a good solution either, just more socialism, a miserable failed model.

I'm also disappointed the Rs have not offered a solution yet, however Trump says he plans to unveil one soon. I'm looking forward to seeing it.

Here's one possible path for our future healthcare: first, start with a phased approach on this, prove out success models first. A number of Government sponsored pilot programs would be launched across USA, a cooperative set of pilots with FED, State gov and private sector players. Let Buffett/Bezos/Dimon project be one of the pilots. The pilots could be overseen by bipartisan panels of professionals. We give them a full 2 years to see what works and what doesn't.

The pilot I'd propose would include this: what if we transition all healthcare provisioning (Doctors, nurses, actual provision of care) to a complete non-profit model yet a competitive non-profit model? The model would include many non-profit entities which can be National in scope, owning hospitals, doctor offices, clinics, etc. This keeps the government out of it.
This keeps it in private sector, keeps healthy competition between the new health provider NGOs, sanctioned and regulated by both Government and independent citizen run boards. It could be paid for by increased taxes on our payroll, comes out of the paychecks just like private insurance. The difference is, you as employee have right to decide which national NGO you affiliate with, akin to your choosing your insurance company today.

This model would only cover all basic and complex needed healthcare. Elective healthcare (plastic surgery for vanity, other such care) would be elective and only covered by those with gap insurance to cover such vanity care.

Bottom line, as a conservative Republican I also believe we ought not make a profit off of human illness, or perhaps better to say human wellness. However, that does not mean the profitable pharmaceutical industry or medical device/equipment industry goes away. Their customers would be the NGOs. However, this new system would also include major new incentives for driving cost savings in delivery with NO compromise on quietly of care.
My idea for how to better regulate drug industry is another part of this pilot.


On rough back of napkin analysis we all know trillions could be saved if the current healthcare costs were put back into the realm of reality. Healthcare costs have no reason to be increasing exponentially compared to cost of food. The only reason they have is due to the dysfunctional system.

Doctors and nurses should be well paid, yet they all need not become multi multi millionaires either. By going to an all NGO provider system, and phasing out insurance as we know it today, there's plenty of $$$ in the system to sustain good incomes for the providers, as long as they are delivering quality services.

The new “health insurance" would simply be what NGO pool do you join and pay into. There would be actuaries and insurance professionals sorting out the administrative efficiencies, the big difference is they wouldn't be at the mercy of making profits and keeping wall street investors happy, they'd instead be laser focused on delivering the highest quality healthcare at best price. This model also forces the private industry delivering drugs, equipment and devices to all be competing for the NGO dollars yet everyone competing on a level playing field with profits taken out of the equation for the providers.

Of course if you make a great drug, device, equipment, you can still be a for profit company. The best and most efficient solutions win the greatest number of NGO provider contracts. This keeps Wall Street engaged, American investors can still invest in leading pharmaceuticals and medical equipment manufacturers.

Who are the big losers here? The private insurance companies. I don't feel sorry for them. They have failed at their job, I'm fine to see health care insurance phased out and replaced with a new model of NGO run non-profit “insurance."

Eventually, you can imagine specialized NGOs developing, around cancer, diabetes, etc. These could be national consortiums laser focused on cancer treatments and cures. You may belong to a national health NGO that covers all your basic family healthcare needs, but if someday you get cancer you then switch to the NGO specializing in this. Again, there could and should be many to choose from as it would be a national system of many NGOs, the biggest and the best have the most subscribers/members.

Doctors and nurses would want to work for best run NGOs, healthy competition keeps everyone on their toes.

The biggest problems today with healthcare delivery are unbridled cost overruns and inefficiencies. Too many hands on the cookie jar and private insurers control the cookie jar.

Let's phase into non-profit delivery nationwide and drive both technology advances and cost savings by ridding ourselves of the insurance industry leeches.

> I definitely think the Republicans are more responsible fiscally....

Let's look at the facts over the last 4 decades: The last two Democratic presidents have reduced the deficits - including a budget surplus from Bill Clinton. Name a republican who has run a budget surplus, at any time in history.

The last FOUR Republican presidents have massively increased the annual deficit: Reagan tripled it, GHWB raised it by a third, GWB doubled it, and Trump is blowing it up a trillion at a time after promising not to do so.



> Trump says he plans to unveil one soon.

Trump had complete control for two years and did nothing. But I agree, belief is a wonderful thing. I believe I will someday be 6'4", 235 lbs, <8% body fat with a full head of hair. I can't wait! Really! Gonna happen!



> what if we transition all healthcare provisioning to a complete non-profit model yet a competitive non-profit model?

Interesting. Points for an actual plan. Creative. Does this include the for-profit insurance industry - make them non-profit?

The main issue is not cost or access per se. It is pre-existing conditions.
Over 1/3 of the population and most senior citizens have pre-existing conditions.

Most people are too cheap to pay for the average cost of care for everybody. They only want to pay for the actual cost of care for themselves when they are healthy and wnat somebody else to pay for their care when they become unhealthy.

Americans tend toward individualism and are led by a sociopath. Other countries have a more communal sense. Cost-cutting and logic are not sufficient to solve the American health care issues. The same lack of empathy that does not allow mass killings to be eliminated causes health care to be each to his own situation.

@any plan,

Yes, my idea is to transition to a complete non-profit model, for healthcare delivery, with great flexibility for the private sector run NGOs to organize this. It could include a model whereby it's based on member fees, that is the new health insurance. Yet there is completion for members by the nationally organized NGOs.

Drug industry, medical device and equipment industry would remain for profit private sector run. They focus on the technology solutions. The providers focus on the delivery of service, which is what would be completely not for profit. For profit insurance is phased out, that would require a very creative solution but I believe we could do it. The vast majority of Americans want this fixed, but it must be fixed without Government taking it over.

I don't agree with your analysis on the other fiscal issue and budget deficits. For example, Reagan in particular was hugely successful. While he did pump up the deficit in the short term, it was mostly due to Reagan's economic policies and deregulation policies that all laced the groundwork for a very strong economy for most of the 1980s. Then, due this massive push forward it capital formation and deployment, it exponentially continued its drive forward in the 1990s, after a typical cyclical recession in 1989-91 period. Clinton actually did not mess much with Reagan's economic policies, and Treasury Secretary Rubin told him to stick with it and he'd reap the rewards. And so he did, Slick Willy was in the right place at the right time. It was the booming economy that generated the cash flows that resulted in decreased deficits. It was the success of private sector activity that erased the deficit.

In the 1990s the massive productivity gains and capital infusions from the dawn of the Internet age drove most of the booming economy until the dot.com bubble burst. Moreover, Reagan's policy to double down on peace through strength helped push the Soviet Union into collapse and the peace dividend helped as well (again mostly Clinton benefited from this result of Reagan policies).

Sadly, 9/11 tragedy ginned up a very unfortunate war strategy led by the ill fated and poor judgement of a small cabal of neocons who captured and ran with the ball. I do fault Bush for this and I did not support the Iraq war. Trump also did not think it was a good idea. However, that does not mean I abandoned my party or it's very laudable goals and principals of fiscal restraint, small government as possible, efficient government, peace through strength, etc, etc.

But this blog is about healthcare, and I think it's time for Ds and Rs to work together on a solution. Somehow I don't see the likes of Cortez, Pelosi or Schumer providing any good faith effort to work with the Rs.

Geez, you go on quite the rant trying to defend republican fiscal irresponsibility - please get the facts straight: Reagan tripled the national debt from ~$900B to $2.7T. He didn't just increase it "in the short term".

He had 11 tax hikes on the middle class, several recessions, and his administration had more indictments than any other.

But sure, Clinton was "lucky".

Fact: 2 D presidents reduced the deficit. 4 R's increased the deficit. Democrats are the fiscally responsible party.

We agree - for profit insurance has to go in order to reduce healthcare costs, along with other moves.

so re the topic:

No party can talk about the down and dirty, nuts and bolts of cost reduction in a political setting. The GOP doesn't even offer a plan - they certainly learned not to get specific, let alone ANY plan. Therefore, I reject the frame of the question, Mr. Levy, though an interesting discussion.

The path to cost reductions, imo, is to start with Medicare buy-in for all. Force the for-profits to compete against the low overhead of Medicare.

Other immediate small steps have all been covered: re-write the Bush law that forbids Medicare from using their massive buying power to negotiate with pharma, and a number of other common-sense fixes, as we transition to universal.

If every other major country can cover their citizens at less cost and better outcomes, why can't America do better?

As for the GOP? Isn't it extraordinarily embarrassing to not even have a PLAN?!? We expect that of Trump, he's a narcissist who can't read a 1 page summary without pictures, but the rest of the party - no plan at all?

I tried that in 2nd grade. The teacher wasn't buying my excuse - the dog ate my homework. She knew we had a cat.

...in a political setting, *during an election cycle.

@Chris

My proposal would include coverage of pre existing conditions.

Too bad for those who are cheap and don't want to pay. They either join a ngo and pay the member fee to get their healthcare, or if not they will pay top dollar when they need care. There would be clear economic incentives to join a program, and you and/or your employer pay the monthly fee. It would be about same cost as anyone paying for insurance today, less for those who pay individual plans today (which are very expensive if not with big corporation).

Due to cutting out the leeching insurance company costs, yet having cost control incentives, delivery services would have lower costs and competition between ngo providers for both members/patients and doctors/nurses would keep quality high.

The “single payer" concept may even be possible where Fed Gov handles payment of the premiums however the consumer always has control over which ngo healthcare provider they choose to direct their payments to. Pricing on all services would be transparent. This is why we ought to start with various pilot programs to test out different models.

> to test out different models.

Martha: where are you on the 3 existing US models?

- for-profit
- single payer
- the "socialized medicine" VA (which has great outcomes and better costs, when funded correctly)

Would you just hybrid the single payer solution (in the form of non-profit insurance) and existing for-profit delivery of service and goods, and ignore socialized?

Posted by any plan is better than the gop repeal, a resident of Menlo Park: Menlo Oaks,
1 hour ago

>> Martha: where are you on the 3 existing US models?

>> - for-profit
>> - single payer
>> - the "socialized medicine" VA (which has great outcomes and better costs, when funded correctly)

>> Would you just hybrid the single payer solution (in the form of non-profit insurance) and existing for-profit delivery of service and goods, and ignore socialized?

You know what I would like to try? Let's try a hybrid socialized/for-profit model like this:

Anyone and everyone can use the socialized medicine system, including the middle class and rich. Taxpayer-funded, no cost-recovery from the wealthy, because, excessive accounting exercises (see the NYTimes discussions of codes and coding) greatly increase the cost of delivering service. Instead, the benchmark is what other countries that have been doing socialized medicine for 70 years have found to be cost-effective. Rich people wait in line like everybody else. Taxpayer funding is at a fixed fraction of GDP based on what socialized medicine has been costing other countries in recent decades. I'm guessing the lower-income 50% will mostly use this system.

And, a for-profit system for anyone who wants it. Reduced waiting time, immediate care, cosmetic enhancements, procedures that marginally increase life expectancy at great cost. Anyone can pay cash. I'm guessing the upper income 50% will use this system quite a bit, at least, during peak working years when time is money.

> the upper income 50% will use this system quite a bit, at least, during peak working years when time is money.

I'd certainly look at that.

re the upper 50%, I think some of us overvalue the amount of money in the 51-80th percentile. That said, locally, yes (those tech engineers! are they above, say, the 80th?) And the top companies will likely still participate at some level as incentive.

Overall, corporations would love that plan - they really want to get out of the business of middleman for insurance companies, and obviously, the cost.

It would also, due to lower corporate costs, make US goods more competitive to those manufactured by companies without healthcare costs.

And we have to get Pharma money of out DC and the statehouses so we can work on that ridiculously inflated cost.

@any plan,

First, as a conservative Republican, I always start from this POV: how can we solve large complex national problems with the least amount of Government intervention, yet achieve highest efficiency, transparency, accountability, all while delivering highest quality?

When you think about it, most American corporations and private industry overall, from SMBs (largest segment) to Boeing, have an excellent track record of delivering their goods and services while achieving all of the above. While government has a lousy track record for delivering services.

Nothing in life is perfect, but our experience going to our favorite “mom and pop" restaurant or small shop, to our sitting in a Boeing 777 about 35,000 feet above the Amazon jungle on our way to a very important business meeting in Sao Paolo, Brazil, is impressive. Both experiences are made possible by people in private sector. I for one appreciate all those thousands of workers, managers, corporate leaders and investors who make all of this happen. When I get back home to my well built house with the finest woodworking (despite the many headaches dealing with contractors), I still marvel that men with their own small business made my house extremely beautiful and comfortable. Thank God the US or California Governments were not involved in any of this activity (especially the airplane ride). To be clear, of course the government was involved with some aspects, yet overwhelmingly everything described above was done by people working outside government controls or supervision.

The reason I give this long background to my answer is because the full concept, the full understanding and execution of a private sector led economy and society is very critical to appreciate before discussing any government policy to solve for massive “public good" problems (in this case health care).

In my early training (MA from School of Public and International Affairs, Columbia University), we were taught all the theories behind government systems, and the concepts and theories behind delivering public goods vs. private goods. I attended Columbia back when they still taught truth and did not propagandize. Healthcare for humans is a public good. Now, let's solve for it in the USA with the least amount of government intervention yet following all the principals above.

You asked where do I fall with following models:

- for-profit
- single payer
- the "socialized medicine" VA (which has great outcomes and better costs, when funded correctly)

“Would you just hybrid the single payer solution (in the form of non-profit insurance) and existing for-profit delivery of service and goods, and ignore socialized?"

Short answer is yes, however my suggested delivery model is completely non profit. That is the key: non profit delivery. The main concept here is the delivery of healthcare services is completely non-profit, yet the government is not involved in delivery either, except for regulation and licensing. However this is why we ought not try and solve this so quickly, go as quickly as possible but not recklessly. Develop multiple competing national scope pilot programs, we ought start a transition based on proven success models.

Obamacare was a disaster since the Ds tried to ram one huge “solution" down all our throats at once with very unrealistic components (especially who will pay issue). The best two quotes (lies or deception) summed up how and why it would not work: “You'll be able to keep your doctor" Obama (not true), and Pelosi's “we can't know what's in the bill until we pass it." (Absurd and deceptive)

Imagine if we ended up with many dozens, if not hundreds, of national and local Healthcare Delivery Organizations (HDOs: a non-profit entity that is licensed and regulated by Fed and States to focus 100% on the delivery of human healthcare services, with minimal government intervention).

Doctors and nurses could finally belong to non-profit entities whose mission is one of the highest callings for humanity: how to keep people as pain free and healthy as possible to lead happy productive lives. The HDO board's would be comprised of doctors, nurses, private sector leaders, and workers/reps of the “customers." However, remember doctors don't make great business or operational delivery services leaders. There are people that are best suited to be on these boards, brilliant administrators. Yet let private sector decide how they staff their boards. The best managed HDOs will end up being the most successful, most members, most corporate contracts, attract best doctors and nurses, etc. Delivery stays competitive which is good, yet profit motive removed.

Doctors and nurses would still be well paid. Leading Doctors could still become wealthy as perhaps multiple HDOs would pay for access to their talent. This system allows for excellence and rewards excellence and leadership. Technology and private sector creativity makes many new delivery breakthroughs possible. In this model the drug companies, equipment and devices can all remain for profit.

SMBs could have the ability to join national cooperatives that join the HDOs too, or have multiple options to provide their employees to join different HDOs since this model gives a small restaurant the same access to economies of scale as Google enjoys.

There may be a “socialized" component too, in that the payments could be processed through the Federal Medicare payment system. Yet I'm not sure about this yet. We need to keep Medicare as is or phase it out on a separate track for a variety of reasons. This system is for the 18-65 year olds, active working age people.

It's best if private business is invested in their employees healthcare, so it could be best if the private citizen can receive the benefit of their employer subsidizing their payment into the HDO, as they do today with for profit insurance. The corporations can write off their subsidies as an expense as they do today. This is good for society since it promotes working and getting benefits as part of the process.

The problem to solve for is how to ensure the SMBs, the self-employed and people not employed are all covered. If the system is National in scope, and individuals and SMBs can basically benefit from the same cost structures Google gets for their employee plans, then this would be the goal. If the for profit insurance is phased out, this can be possible. The pools of healthy people subsiding the unhealthy would work out, especially with profits removed.

For now, let's assume the new non-profit HDO system is rolled out in phases (or in fact might be better to flip the switch at once nationally, and give the insurance companies time to phase out). I know, not easy! We have a multi billion private health insurance industry, yet their interests pale in comparison to the drag they have added to our economy (including our global competitiveness). As I said before, they failed at their job (they were supposed to keep costs down while delivering quality care to the masses, didn't happen). When companies fail in “real world" economics, they go out of business. To date, their success and profitably are artificially protected and subsidized. They are not even operating in a classic competitive marketplace, nor should they since healthcare is a public good.

Oh, please.

"Obamacare was a disaster"

Then why didn't it get repealed and replaced?

Americans really like it. and Republicans don't have a replacement, because as someone explained above, Obamacare *is* the Republican plan.

Obama should have gotten rid of for-profit insurance.

Your fantasy of nonprofits delivering in this day and age is just that, a fantasy. Very wordy, though.

No constituency.

Not a fantasy. It was how many hospitals used to operate, run by Catholics and other non profit entities. Many hospitals are still non profits. It's the private insurance that has mucked it all up.

Doctors aren't great business managers, so they gave the management of their “business" away to the insurance companies who then leeched off their services.

Yes, Obamacare was a disaster, at least about half the voting age population believes this. About 60 million Americans did not like Obamacare. Moreover, it had no long term payment solution, it was unsustainable without major reworking. It also further inflated costs, it pumped more subsidies into the system with no cost controls. It solved nothing except made some poor people get access for less cost while others just over the poverty line paid a huge amount for access to subsidize the very poor or lazy.

Yes, complex solutions do require a lot of words.

I've provided my outline for a plan, where's yours?

> Yes, Obamacare was a disaster

"Fox News poll: Obamacare more popular than GOP tax cuts"

Kaiser: 48 approve 41 disapprove
Web Link

RCP, 2017
+7.6% (it's higher now)
48.3 For/Favor
40.7 Against/Oppose

Wm Burton asked: Then why didn't ObamaCare get repealed and replaced? Americans really like it.


"Yes, complex solutions do require a lot of words."

Actually: "Yes, complex solutions do require a lot of *ACCURATE* words."

Your case would be more compelling if you weren't so consistently wrong on your claims about republican fiscal irresponsibility, ObamaCare, etc.. Why don't you give us a link to your claims?


As for your dream:
I agree with Wm Burton - there is no natural constituency for conversion to non-profits.
- Who wants it?
- Who will drive it politically? Not the GOP - you have yet to answer: what's the GOP plan?


I highlighted my ideas above, if it was me you were asking. Segue to universal with Medicare buy-in for all, repeal Bush restrictions on drug price negotiations, etc..

Mr. Levy's opening statement, two miles up this page at the very beginning, contains some valuable points. The reader responses illustrate some of the complexity involved. Like immigration reform, most zip right past the illegals into moral fantasyland and forget that no one in power on either side wants decent reform. They are just not going to do it. Whether they are protecting cheap labor pools or whatever, no congress has wanted to deliver a fix. We're stuck.
With healthcare, it really must happen in baby steps or, like immigration reform, entitlement reform, etc we'll never get there. Trump has done some good things here - let's get some transparency in drug pricing and billing. Let's get rid of some of the dumb regulations that inhibit change. That's a start.
The four points at the start of this blog are good starting points.

@any plan

portion deleted

Back to healthcare solutions: you and I are actually not so far apart on this. In fact, my plan suggests a potential single payer option using the Medicare platform. It ought to be seriously considered. The main element of my plan is not unrealistic at all given many non-profit healthcare delivery systems already exist (various hospitals and private clinics across the USA). The payments into the system could be administered through Medicare, however the delivery systems would be best if 1) they were not operated by the government and 2) there was competition and choice built into the system.

Long ago there existed a system of non profit catholic run hospitals on the east coast, and other parts of USA. Then by the 1950s through 1970s Doctors started peeling off into the wealthier suburbs along with the suburbanization of America. They tried to create their own clinics and “practices." One thing the doctors learned was they were terrible at administration and operations. Of course in hindsight everyone understood why this didn't work, it's enough to focus on caring for the complex human organism. So then the insurance companies saw an opportunity to take over and the rest is history.

That's oversimplified retelling of history, but basically that's what happened. So here we are today.

Once again, I advocate for multiple pilot programs, let Bezos/Dimon/Buffet be one of the US gov sanctioned pilots. Test out others too. Let private industry and private non-profits take the lead in all the pilots. The beauty of a competitive non-profit run healthcare delivery services system also includes the ability of private insurance employees to transition over to the HDOs (HDOs: health delivery organizations, non profit entities focused exclusively on healthcare services delivery). This new system requires creative new applications of actuarial science and modeling, new methods of statistical modeling of pools of healthy versus unhealthy people and how best to distribute the risk. AI carefully and ethically managed to do this, along with cost savings through creative technologies, and disappearance of massive profit skimming from private insurance, would all result in massive cost savings. It's applying certain age old insurance modeling to a fully non profit endeavor, thereby creating economies of scale and risk distribution along side healthcare technology innovation (which would remain for profit).


George is right, take this one piece at a time too. Trump gets credit for trying new and practical changes. It all must be moved forward by clear vision, consensus, and strong leadership. This big vision could absolutely work if Ds and Rs agreed to work together in good faith. That, sadly, is a very big IF.

portion deleted

Your point?

So, lots of words (portion deleted) and you still failed to tell us who will drive a shift of for-profit companies to non-profit status?

Who? The GOP? (they refuse to support a plan, as mentioned by others, so - not them) The Dems? Nope.

Who?

Posted by George, a resident of Old Palo Alto,

>> [most] forget that no one in power on either side wants decent reform. They are just not going to do it.

>> With healthcare, it really must happen in baby steps or, like immigration reform, entitlement reform, etc we'll never get there.

I agree. My plan, which is pure socialized medicine for working class people (and anyone else who wants it that way) can work because you start at the bottom and work your way up. Start with indigent people and working poor. Use closed or closing clinics and hospitals in rural and inner city neighborhoods. Always free, and free of excessive coding exercises. Work your way up until you get to the population that is willing and able to pay extra to not wait. Don't ever bother trying to cater to the rich and super-rich-- they can use their own segregated facilities.

@Wm Burton,

Who? Well if in a perfect world Rs and Ds could actually collaborate and problem solve in DC they could pass a law on regulating healthcare services that would phase out for profit health insurance. When anyone says let's go to single payer they are basically also calling for shutting down private for profit health insurance anyway.

Forms of for profit insurance could absolutely still exist for wealthy or whoever wants a policy to cover plastic surgery and other non-essential services. Yet every American would have the choice to join a HDO, or not join (in which case they'd pay more for services when they need them).

If an insurance company wanted to transition its healthcare insurance unit to a non-profit, that would be allowed as well. Big question how to deal with investors, yet if done in a 5-10 year transition, it could work. If you're a smart investor you shouldn't have 90% of your portfolio in United Healthcare anyway. As for what happens to the CEO of UHC and his fortune, I'm guessing he's diversified too, I'm sure he'd be ok.

Clearly many details would have to be worked out. I like how Steve Jobs imagined future products, as he described in a speech to Stanford grads. He thought about the end state of the solution or product he envisioned, and then worked backwards to fill in all the steps to get there. We need some brilliant visionaries like Jobs behind this.

It does seem daunting today with the media making it look like our country is nuts. Clearly Congress is nuts, but in my world hope springs eternal. Otherwise we might as well all shut the lights off now! So, I do hope the Ds will return to sanity and get back to trying to cooperate with Rs. I'm also disappointed with my own party on this topic, yet I don't give up on them and I try to participate in the process. In the meanwhile, maybe Uncle Jeff/Dimon and Buffet might surprise us with a brilliant new idea.

I'll stand by my vision, I'd like to see an end state of non profit healthcare delivery services for all, a very competitive yet diverse system of national and local HDOs. No matter what, I don't think a government takeover of healthcare services will result in anything good.

> Well if in a perfect world ...

Okay, you have the perfect plan for the perfect world. Whatever floats yer boat.

In the real world, start with Medicare buy-in for all, and work from there. At some point, anyone without employer subsidized insurance will 'buy-in' rather than pay inflated for-profit prices.

.


> So, I do hope the Ds will return to sanity and get back to trying to cooperate with Rs.

Cooperate how? ON WHAT GOP PLAN should they cooperate? What a farcical statement.

What is the GOP plan that needs D help?

THERE IS NO GOP PLAN.

You admitted it by failing to answer the five times you were asked by multiple posters to define ANY gop plan.

How about the republicans cooperate with the Democrats? They can cooperate on the Republican designed ObamaCare (Heritage, Romney plan.)

@Wm Burton

Ok, you probably missed it buried in the 100,000 other words I used, sort of verbose I'll have to admit. Lol!

I did state that I am disappointed in GOP, although they did try with an alternative which was shot down some time ago. I don't think it had enough support.

I think both Ds and Rs are to blame, especially the Ds. It would take even longer to correct the oversimplification of the Romney, Heritage, Obamacare history.

Once again, I'll always stand by fact that private sector delivery of services is usually far superior than anything the government runs. My plan is worth running a pilot or sketching out a biz plan scenario. Your payment idea is less than 1% of any solution. The key problem to solve is delivery of services, driving operational savings and, keeping cost overruns under control.

You might try to be less snarky in debates. It detracts from any credibility.

They had complete control of the government for two years - 2017/18. What was their plan?

> I am disappointed in GOP, although they did try with an alternative which was shot down some time ago

When? What plan? I honestly can't see through your purposely vague deflection.


> You might try to be less snarky in debates. It detracts from any credibility.

Credibility might not be the issue you should raise - you've been asked over and over the following two questions and offered zero answers:

- What GOP plan?
- Your forced conversion to non-profits: who is the constituency that will drive it? the GOP? the medical field? Dems? for-profit insurers?!?!?



> I think both Ds and Rs are to blame, especially the Ds.

Again: how can you blames Dems on healthcare if the GOP has done NOTHING, offered NOTHING, and fights EVERYTHING?