ISSUES IN THE DEMOCRATIC DEBATES OVER HEALTH POLICY

Merrill Ring (With Contributions from Andy Winnick)

Don’t focus on individual candidates – look to the issues

Preamble
I set out to write for The American Institute for Progressive Democracy (TAIPD) a summary of each of the Democratic candidates’ positions on health insurance/health care. The aim was to present those summaries in order to assist voters in the Democratic primary to decide which plan (and so possibly which candidate) they should support.

However, as I was reading their individual statements and trying to get the material organized in summary form, I realized that that was not the best way to achieve the aim of the project, namely to give voters in that primary election an overview of the various positions in order that they could make an informed choice.

It came to seem to me that the best way to go about the job was not to focus organizationally on each individual candidate, but to present the material in terms of issues and only then to try to sort out the candidates’ positions on those issues (at least for some of the candidates on some of the issues depending on the availability of information from them).

I also do not think it important to seek out what each individual candidate has to say – for many health policy is not their issue, is not where they want to make a contribution to the ideas the Democratic Party should be advocating and standing for.

Moreover, it is not important to consider the details of any plan since when such a plan goes to the legislature for enactment, it will be altered (by what is often called ‘the sausage machine’) so much that even important pieces of it are changed.

So what I present here is an overview that I think it is quite informative. Along the way I offer my own opinions (reasonable ones I hope) on some of the issues raised. I publish this for TAIPD, but it is not to be inferred that what I say here is the official view of the institute, no more than that a newspaper is responsible for the views of its columnists.

Note: Andy Winnick has made contributions to this version of the piece: he has a command of statistics that I don’t have and so when you come across statistics in here they no doubt should be attributed to Andy. (It must be pointed out that he has added items other than the statistical.)

Health Policy
The ordinary way of putting the topic – in the debates, in candidates’ statements, in the media – is that the focus is the issue of health care. That way of stating the question is importantly misleading.

The central bone of contention is the matter of how should Americans pay for health care?

The nature of our health care itself is a different issue, an important issue,. but not the main one being debated by Democratic candidates and by Democrats.

In fact, many of the candidates, in their statements do offer proposals concerning the care of our health (e.g. Should we allow nurse practitioners a greater role in health care than we do? What new health services should be covered?) There are also further issues, at least one of which is widely addressed by the candidates: the overall cost of our health care.

There are thus three different issues raised by the candidates’, and thus three different issues that face the Democratic Party and voters:
1. That of health insurance (How should Americans pay to get health care?)
2. That of how to contain the costs of health care in this country (which is far and away the highest in the developed world).
3. That of health care itself (Are there adequate medical facilities in all areas of the country? Could/should we allocate responsibilities differently among medical practitioners?)

But those two further issues all take second place in the candidates’ views and in our concerns as voters to the question ‘How should we pay for access to health care?’ Consequently, this essay will primarily deal with the first issue.

The best terminology for the overall set of concerns would be that the debate in the Democratic primary concerns health care policy. That covers all the various issues that should be mentioned in the current discussion.

However, I don’t expect the standard terminology (which refers to the issue as one of health care) to go away – in fact, I will sometimes indulge in it myself simply because it is the standard way of talking. However, it needs to be remembered that there are different issues being raised; the candidates frequently respond to different ones in the same statement of their plans. A reader of those plans must always be asking about what issue is being focus upon in any particular item in a candidate’s statement.

I. Democratic Agreement as to Chief Failings of Our Current System
of Paying for Health Care
A simple listing of what our individual candidates propose tends to omit what they share – and the extent of their agreement is enormous and needs to be cited in order to appreciate just what the Democratic position is in general.

They all agree, first, that our current best shot at providing Americans access to health care, namely the Affordable Care Act (ACA) also known as Obamacare, while a huge leap forward, is nonetheless inadequate in that it fails to cover large numbers of people who should be covered. We lag far behind the rest of the industrialized world in the number of people who fall outside the insurance system. The latest count is 30.4 million uninsured Americans, which is 9.4% of the population. Moreover, do not forget that many who do have insurance are underinsured. Sanders has recently estimated that 87 million are either uninsured or underinsured.)

All the Democratic candidates also agree that individual Americans pay very much more per individual for their health care than do people in other industrialized countries. According to the Centers for Medicare and Medicaid Services, the U.S. spends more than $10,700 per capita on health care, the U.K. $4,826, France $4,902, Germany $5,728. Moreover, we spend almost 18% of our GDP, whereas these other counties spend less than half as much.

Even so, it must be said that our health care outcomes are among the worst. The rate of child mortality is the worst among the major industrialized nations. The rate of women dying during child birth is the highest, in fact higher than in some underdeveloped nations. Our life expectancy is 2.5 years shorter than, for example, Germany. Our five-year survival rate after a stroke or heart attack is worse than in most other industrialized nations. So one has to ask, just what is it we are getting for all the money we are spending?

On top of these concerns, all of the Democratic candidates share the nation’s shame that we allow millions of people to be unable to pay for their health care or unable to pay for adequate health coverage, on top of getting worse outcomes than most other developed nations, even after we spend so much more on health care than comparable countries.

II. Democrats Agreed Upon Goals for Health Care Policy
In response to those failings of our overall health care system, all the Democratic candidates agree that the solutions must:
1. Attain universal coverage, i.e. access to health care for all Americans
2. The health care provided must be affordable to all individuals, i.e. the cost of providing health care to Americans must be decreased until it is in line with comparable countries and in line with the incomes earned by Americans.

III. Solutions to Achieving the Health Policy Goals
If one surveys the world to see how comparable countries have achieved their success in outdoing the U.S., it will be found that there are quite a few different solutions.

However, the time has come for action and, perhaps regrettably, it is too late in the game for this country and the Democratic Party to have an extensive evaluation of all those successful kinds of solution.

There are, represented in the slate of Democrats running for President, only two live solutions to our health insurance crisis, i.e. only two of the possible solutions are seriously on the table for Democrats. Of course, there are many variations in the details between candidates, but in general outline there are only two being seriously debated.

We all know what those two are:
 Extending and developing the current system, the Affordable Care Act (ACA or Obamacare) to include as a “Public Option” the Medicare program.
 Some version of Medicare for All (MfA) as a single payer system into which everyone is enrolled.

Both of those solutions aim at providing universal access to affordable health care, which is the stated goal of the Democrats’ debate on health policy.

There has been created an analogy to the difference between these two solutions. The difference is said to be like a choice as to whether to remodel your house (ACA) or to scrap it and build a new one (MfA). That is not quite right. For what the MfA does is to move our health insurance to an expanded but already existing program, Medicare, and enroll everyone in it. By analogy, this solution would be like moving down the street into a small jewel of a house and remodeling it. (Of course, the old house (ACA) is abandoned.) Note: that analogy is technically not quite right as Medicare and other insurance programs (Medicaid, CHIP) will be collected together in one new agency.

IV. Who Supports What?
Of the 12 remaining (at time of writing) top Democratic candidates, Joe Biden is the one who is most identified with the ACA solution. However, Amy Klobuchar and Pete Buttigieg are the best defenders of the position. Tom Steyer (and Beto O’Rourke before he dropped out) are also ACA supporters.

On the other hand, Bernie Sanders is (and has long been) the champion of Medicare for All (MfA). Elizabeth Warren is a very important proponent of this solution. Julian Castro, Corey Booker, Andrew Yang and Tulsi Gabbard count themselves as supporting the MfA solution.

Kamala Harris’s plan is something of a hybrid. In so far as I understand her scheme, she advocates allowing private insurance within the Medicare system – a combination similar to the way the present Medicare Advantage program operates within Medicare.

(Note: Both Harris and Buttigieg were, earlier in the campaign, supporters of the MfA solution (in fact Harris was a co-sponsor of the Sanders’ bill.) Along the way, both changed their original position, Harris keeping some allegiance to MfA with her hybrid position, while Buttigieg retains only the name of what he originally signed on to, calling his proposal Medicare for All who Want It.)

VI. Defects in the Current Democratic Discussion
Before looking at the two options in some detail, it is necessary to point out some very serious defects in the discussion concerning our health care policy.

The first matter to be complained about is the candidates’ statements about health on their campaign web sites. These are very inadequate, often poorly written and organized. And they are certainly not at all comprehensive, i.e. many crucial issues are not so much as mentioned. (That is one reason that organizing this work around issues rather than individual candidates is the way I have chosen.)

I shall then list some of the most vital items that are almost universally missing from the various statements. The chief exception is Bernie Sanders who has been talking about these matters for a long time and also has the advantage of having written an actual bill (Amy Klobuchar has also written many health policy bills).

1. Though there is probably agreement by all the candidates about what medical issues are to be covered in a revised health insurance policy, their statements of that policy for the most part omit reference to the topic. There are some indications that the assumption is that not only what we currently regard as health issues will be covered, but also dental care, vision, and hearing are to be included. If that is the assumption by the candidates, it is not mentioned in most of their campaign proposals. It is of note that most statements do talk of mental health as being covered and a few mention contraception. Most statements, Booker, Sanders and Warren being exceptions, do not address the very thorny issue of long term care.

2. Surely any policy must set limits on what will be paid for under the accepted plan. Medical devices form the easiest example here. Supposing that the cost of wheelchairs is covered by the health policy – are only push chairs to be paid for or are motorized chairs also covered? Are prescription sunglasses available to anyone who wants them or only to those whose doctors say they are necessary? I don’t think that there is, in the candidates’ plans, any discussion of whether there will be limits on what treatments are made universally available. On the other hand, those issues are perhaps of secondary importance and would be ironed out when the actual bill is created in the legislature.

3. Defenders of both the two main positions, though especially defenders of the MfA solution, fail to address the issue of whether supplemental insurance will be allowed. Supplemental private insurance would be a private insurance policy that enables the customer to have treatment beyond what is covered in the basic option: if only push chairs are covered, a customer who wants to spend money on a supplemental policy may be insured so that he/she could have a motorized chair. The matter of supplemental policies is not distinguished from there not being private insurance for the basics. Does the claim (Sanders) that health insurance companies will go out of business if MfA becomes law really mean that supplemental policies also will no longer be available? No one is making that clear.

4. What forms of medical practice will be covered? That is presently not part of the debate. Given what the ACA presently covers, it is likely that acupuncture will be covered in the future. And probably also chiropractic. What else is in and what out? Witchdoctors almost certainly won’t be covered. The field of mental health has very many quite different forms of treatment, a diversity which will cause problems in deciding what to be publicly paid for and what not.

5. Is it only American citizens who will be covered by whatever solution is accepted?

VII. First Solution: Improving the ACA
The aim of this option is to extend and develop the current ACA system. This way of redoing our health care policy continues the practice of having people purchase (in a variety of ways) health insurance from private, most often for profit, corporations. The ACA requires that all such policies meet standards of health care (no junk policies). It provides public assistance in purchasing private insurance, the amount of which is determined by one’s income. It also allows the individual purchaser to decide what level of cost and thus of care they want paid for (Silver and Gold plans). There are also some provisions for special subsidy payments to the private insurance companies when someone cannot pay their deductible or co-pays, although the Trump Administration has blocked much of this.

What all those Democratic candidates who advocate continuing this method of health insurance for Americans want to do is to provide for consumers a public option (something that was in the original ACA proposal but was too quickly dropped by Obama). The public option would enable the person to join Medicare rather than buying his/her insurance from a private corporation. (That is, people would have the choice of ‘opting in’ to public insurance.) In fact, that addition to the ACA is presumed by its proponents to be so excellent that the wise consumer will end up choosing it rather than a private plan, at least in the medium run.

VIII. Why Support an Improved ACA?
It is necessary to ask ‘Why should we support he expanded version of the ACA and not the alternative (MfA)?’ Sadly, not nearly enough time is spent by defenders of this policy in answering that question. (I don’t mean to imply that those who urge MfA do a better job – that remains to be seen.)

1. To Whom it Appeals
The improved ACA solution appeals to people who are more cautious (I won’t say ‘conservative’) – it represents the least change aimed at achieving the Democratic policy goal of universal coverage.

Moreover, it becomes very obvious in the debates that those who are comfortable with capitalism, at least with regulated capitalism, support this option while more severe critics of capitalism support the MfA solution. (Recall that Hickenlooper and Delaney, while they were still in the race, attacked the MfA as being a socialist solution.)

2. The Biden Answer
Joe Biden seems to recommend improving the ACA only because it is what Obama had enacted and because he was a proud member of the Obama team. That is, I can find nothing in his position that constitutes an argument that this is the best way to go.

3. The Chief Argument
The most popular line of argument in support of this option goes something like this: “The ACA has worked wonders in getting so many more Americans insured – all that we need to do to achieve the desired universality is to improve how it works. It is important that we allow Americans to keep their present policies if that is what they want and not force them into a new system. However, we need to add a public option which will give Americans a further choice.”

While the candidates (and of course other Democrats) have slightly different versions of that line, it is the most common defense for retaining the ACA.

What does that argument rest upon, what is its foundation? It starts from the premiss that public policy must begin with what individuals want, what choices they would make for themselves. The presumption is that a good policy will offer Americans the widest range of choices and that they will end up choosing what is best for themselves. According to the candidates who offer this way of insuring people, the remodeled ACA is thus far superior to the MfA in that the latter does not offer a range of choices – it creates a single structure for health insurance into which all Americans must fit. Hence, the recommendation is to choose a candidate who rejects the MfA route and vote for one who defends an expanded ACA.

This line of argument is very appealing to Americans since the ideas in it are deeply embedded in our political talk and thought. Those ideas are an expression of American individualism, the idea that we are and ought to be free to do what we want.

However, just as individual freedom is not the only value we Americans hold (remember “with liberty and justice for all”), it is to be expected that not everyone will buy the argument for an expanded ACA set out above. The chief reason for accepting MfA rests on a completely different set of ideas, ideas about being a member of the community of citizens of the country. When I get to the discussion of the second of the two alternative policies facing Democrats (MfA), it will become clear what the very different justification for accepting that alternative is.

4. Klobuchar’s Argument for expanding the ACA
There is a second very strong argument for the ACA option that is developed by Amy Klobuchar. While she also indulges in the orthodox argument set out above, she also has a much more specific reason for choosing her position, namely the ACA with a public option. "On 'Medicare for All,' I think it is something we should look at, but I want to get there quicker…" she said in an interview with CNBC. In the 3rd debate she more or less repeated the speed issue: “That's in four years. I don't think that's a bold idea, I think it's a bad idea.”

Her thesis is that we should adopt the improved ACA option because it gets us closer to the aim of universal health care more quickly than the MfA does. I think she has two things in mind for why her position will achieve the agreed upon aim faster than the other way: one is that the arguments about the MfA will drag on for some time and secondly that the Sanders’ plan has a four year transition period – meanwhile, she assumes, many people will remain uninsured. She thinks Democrats (and the country) should go the expanded ACA route because it can be both passed without nearly so much acrimonious debate and, since the ACA is already in place, it can be initiated much faster than MfA.

She argues that under the Sanders’ plan, and probably under any version of MfA, it will take a significant amount of time, in Sanders’ plan four years from the bill’s passage, to get the entire population covered by a new version of Medicare. In the meanwhile, all those people currently without insurance would remain uninsured. We would be leaving them in the condition that all Democrats condemn and are trying to eliminate. Hence, we need to go with the expanded ACA as it gets us where we want to go much more speedily.

That is a powerful argument for holding on to the ACA. I think that any Democratic decision about where to go on health care policy must take it into account, that is consider what is to be done about the currently uninsured while the MfA is developing.
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However, Klobuchar’s issue of what is to be done about the uninsured during the transition has in fact been taken into account by MfA defenders.

The Sanders bill, which is supported by Warren and others, allows all Americans to buy into Medicare in year 1. Thus, the uninsured are not being ignored, as Klobuchar assumes, while the MfA would be going into effect.

Moreover, the transition plan in Sanders’ bill also lowers the age when one qualifies for, and is automatically enrolled, in enhanced Medicare, i.e. with dental, vision and hearing benefits, i.e. without having to “buy in”. The bill lowers the age to 55 in the first year, 45 in year two, 35 in year three, and includes everyone in year four. A currently uninsured person would thus automatically be enrolled in in the first year of MfA if they are of age 55 and so not remain uninsured. It will take time, however, to get everyone automatically into the program.

The transition plan also has other advantages. It lowers the Medicare out-of-pocket cost for everyone in the program in year one, and also eliminates the Part A and Part B deductibles for everyone in Medicare starting in year one. It also eliminates in year one the two-year waiting period for individuals with disabilities to enroll in Medicare. Finally, it provides for continuity of care for persons with private health insurance coverage (whether paid for in part by the ACA or not) to ensure that they are not left without coverage.

In short, the paradigm MfA proposal has an array of responses to Klobuchar’s argument against the MfA solution.

It should be noticed that Klobuchar does not reject MfA in the long run: she is not worried that it is ‘socialist’. She adds somewhere that it is “aspirational”, something that we may aspire to. So, for her, in the long run, replacing the revised ACA by MfA may be the way to go. However, in her view, it is not what we must advocate and pursue now.

Notice also that her idea that since the ACA is already operational we can move to expanding it to include a public option (Medicare) more swiftly than adopting the MfA scheme relies on the idea that MfA is like building a new house. I have pointed out that that is not so: Medicare also already exists.

Finally, Klobuchar makes it sound like we can more or less immediately insure all the uninsured through the ACA. Could it really be done more swiftly than the transition plan advocated by Sanders and Warren? In claiming that her plan can be achieved more swiftly than the MfA solution, she is making an implausible assumption.

5. Castro’s Objection to the ACA Expansion Solution
Of course, those who support the MfA solution will have lots to say about why it should be adopted; some of those arguments will be in criticism of the ACA solution. While they will be examined later in the appropriate place, there is one objection to the solution we are presently considering that does not rest on the (claimed) superiority of MfA. That problem needs to be examined here.

It was raised though, not clearly enough, by Julian Castro in one of the early debates. What Castro did was ask the question, specifically directed at Biden, of whether Biden’s, or any ACA-based solution, would or could achieve the Democratic party’s aim of achieving universal health care coverage.

What Castro was referring to in questioning Biden was this line from Biden’s web page concerning his health care plan: “He’ll also build on the Affordable Care Act with a plan to insure more than an estimated 97% of Americans”. (https://joebiden.com/healthcare/)

Castro’s claim was that Biden’s version of the ACA solution would, in Biden’s own words, leave 10 million uninsured Americans. (97% of a population of 327 million is 317 million, a difference of 10 million.) That it, the ACA solution would not achieve the goal of universality of coverage.

Since there is no reason to distinguish the Biden version from others, this line of argument objects to any version of the ACA solution as not doing what it sets out to do, namely provide all Americans with health insurance. In fact, such plans (using Biden’s as the model) leave millions of Americans without insurance.

Castro did not (and, so far as I know, has not) pursue this matter. The chief question to ask next is ‘Why does that happen? Why will there be uninsured people under the expanded ACA solution?’

The broad answer is: Because people have to do something in order to get coverage under the ACA – they have to sign up for a policy. And not everyone is capable or willing to accomplishing what is required of them to acquire a policy.

It is worth sticking in here some material from Pete Buttigieg’s health policy ideas before trying to see why the signing up process defeats many people. Buttigieg is a supporter of the improved ACA solution which includes a public option enabling the person signing up to join Medicare rather than a private plan. He cleverly and misleadingly labels his position ‘Medicare for All Who Want It’. That is, while he is on the ACA side, he makes it sound as if he is supporting MfA by putting the idea of choosing the public option as the very title of his plan.

In his criticism of Sanders (in the September debate, and again in the October debate), Buttigieg said:
“I trust you [an American person] to choose what makes the most sense for you”. That is, he accepts the standard defense of the ACA solution, that we must start with what individual persons want, with what they would choose. However, he adds to that the assumption that people will make the choice that “makes the most sense to them”, i.e. they will choose that which is best for themselves. People are rational and capable of making the choice that best suits their own individual circumstances.

One must first challenge Biden’s assertion that only 3% will fail to sign up for the ACA. After seven (7) years of the ACA under the Obama Administration (i.e. in 2016), there were still 9.0% of Americans not enrolled in the ACA, that amounting to 28.6 million Americans. After the negative efforts of the Trump Administration, those figures have grown considerably worse, increasing to 9.4% or 30.4 million people in 2018. Biden’s assertion that he can cut that by two-thirds cries out for supportive evidence or at least serious arguments. It cannot simply be accepted because he claims it.

Now let us assume that the Biden people are generally correct: that the ACA option will not achieve universal coverage, that it will fail to enroll (at least) 3% of the population (about 10 million people) and that the reason for that is that those people somehow fail to sign up for a policy (much less the very best policy as they see it). Let us further assume that it is their best interest to have their health needs covered by insurance.

Our question must be: why is it that there is that failure, that inability to do what is in their best interest? I am certainly no expert in this matter. The Biden people must have some idea, given that they predict that an amazingly low 3% of people will fail (as compared to the current 9.4%), but they have not published that information. The best that I can find is from a newspaper report: “experts predict that many still will not enroll because of lack of knowledge about the programs, confusion about how to sign up, or unfounded fears that signing up could expose family members who are undocumented to deportation”.

There is probably more – signing up requires a positive act and that involves the ability to comprehend enough of the details of a fairly complex set of choices to feel comfortable. We rational people might have trouble realizing that others face those difficulties – if so, just imagine the homeless person living under the freeway overpass.

It would be very helpful if there were a more comprehensive account of why the ACA solution has failed to achieve the aimed for universality and is likely to fail that test even if it were expanded to include a public option. Perhaps somewhere that information is known, but it is not part of the current discussion.

Some might argue that Biden’s 3% failure rate is, for most public policies, quite good, that perhaps that is the best that can be done. But is it the best that can be done? MfA supporters say no.

IX. Why Support the Medicare for All Solution?
The MfA – in its expanded version, not the current Medicare - achieves the desired goal of universal coverage without effort. That is the first thing in its favor. There is no signing up required. If you are a person, you qualify and will be automatically enrolled. Get yourself to a treatment center and you have a right to receive care.

I have begged a question in that way of putting it. Under MfA is every person eligible for health care? What about travelers, the undocumented, green card holders, those on a student visa? Are they eligible? This issue is for the most part not being discussed in the current debates.

One might infer from how Sanders and Castro put it that everyone who shows up needing health care is eligible to receive it (exactly like what happens in emergency rooms today). For they do not say simply that health care is a right – they say that health care is a human right. And if that is so, then all you have to do to receive treatment is be a person. It makes no difference what citizenship status you have – if you are in the country and need treatment you are eligible to receive it.

That is an inference from how Sanders and Castro explain why MfA should be adopted. That issue, however, has not been made explicit in the current discussion among and about candidates.

1. Castro’s Version
Julian Castro has a variant on the basic MfA scheme (and not a separate plan as some have said). He has heard the supporters of ACA say that there should be private insurance with an opt-in provision for Medicare – and they add that possibility in order to increase an individual’s range of choices. So, Castro, in a move to have MfA allow for individual choice, as mentioned above, includes an opt-out choice: if you don’t want to be covered by MfA, then you, having already been enrolled, can then opt-out and be covered privately under the terms of the ACA. Of course, since Castro does not want uninsured people running around, to succeed in opting-out a person must show that they do in fact have private insurance.

One fact checking organization (PolitiFact) has claimed that there is little difference between opt-in and opt-out. That is false: opt-in rests on the idea that it is the individual’s choice, what the individual wants, that is the foundation of policy – the opt-out provision starts with the idea that policy choice rests on what constitutes the public good and that to provide for individual idiosyncrasy we can then make an allowance for an individual to opt-out. (As I said above, there are conditions placed on the right to opt-out just as there are for California’s recent vaccination law: the law requires vaccinations of all children (there is no opting-in), although if the family can obtain a legitimate medical excuse – the parents cannot simply want their child not to be vaccinated - they can opt-out.) There is a wholly different conception of what the starting place is behind the opting-in and opting-out.

Anyway, adding the opt-out provision to the MfA solution may well be empty, may only be a sop to those who hold that what individuals want is primary in deciding policy – there may not be any private insurance companies remaining that can provide basic health insurance if MfA were to be adopted, even if private firms are not banned from doing so.

It is sometimes said that the Democrats are the party of We while the Republicans are the party of Me. While that is generally true, that progressives think of what is good for the community while conservatives begin with what I want, it does not play out quite that way in this issue of health insurance. While the idea of MfA does not rest on a foundation of individual wants, those who adopt the standard defense of the ACA are in fact employing a conservative line of thought. (That of course is another reason for Democrats to support the MfA solution.)

2. Walk Out Without Paying
The second main feature of MfA is that when a person has received treatment, there is no bill for services that they have to pay, either then or later. In fact, they will not have paid previously any premiums for receiving care, nor have their employers if the MfA program is where their coverage comes from; there are no deductibles that they have to consider; there are no co-pays that they have to shell out for. Of course, the treatment is not free, but the individual is not paying for it directly before, at or after the time of service.

Note: One thing that supporters of MfA have to consider is that provision must be made for not having employers paying the private health insurance premiums for their employees: for otherwise that would result in a windfall profit for employers. That possibility has been taken into account. Warren, in response to it, has argued that employers, especially in large firms if not small businesses, be required to pay a special tax or fee to the new Medicare program to help cover a major portion of its costs. The amount of the fee or tax would be just short of what they now pay directly to purchase insurance for their employees (98% I believe.) Currently, employers pay about one-third of the costs of all private health insurance. There is no reason this money cannot be simply transferred to the Medicare program rather than to private insuring companies.

3. MfA’s Base of Support
Just as the ACA supporters are those who are comfortable with the continuation of capitalism, with having private for-profit companies supply health insurance, those who support the MfA solution are very likely to be those who regard capitalism and the behavior of the private health insurance firms with at least significant suspicion. That background attitude must not be discounted – while it may not be given as an official reason for advocating MfA, it is nonetheless a powerful consideration in whether one looks favorably on a government agency replacing private companies in the field of health insurance provision.

4. Why Support MfA?
The MfA approach does, while the ACA does not, achieve the goal of universal coverage and, from the perspective of the person needing health insurance, it does so effortlessly (there is no deciding what policy to acquire and there is no signing up to obtain it.) Further, the direct out of pocket expenses are non-existent. There are no deductibles or co-pays, and under most of the expanded proposed MfA programs there are no premiums. While Sanders and Warren advocate the latter approach, some supporters of MfA do propose modest monthly premiums for MfA based upon income, with some progressive formula, as part of how the program would be funded. However, under all such proposals the amounts paid by individuals and families under MfA would be a small fraction of the amounts they currently pay for insurance, let alone for insurance plus deductibles and co-pays. This is especially true since a rapidly increasing proportion of individuals and families have been forced by high insurance premiums to opt for policies with lower premiums but much higher deductibles. This has resulted in many individuals and families being effectively priced out of getting health care insurance, despite the ACA, or being burdened with having to pay astoundingly high, often unaffordable deductibles. Indeed, from 2008 to 2018, general annual medical deductibles for workers covered by health private insurance increased eight (8) times faster than wages. Wages went up by 26% (before inflation), while deductibles for these same workers went up 212%.

Moving to the MfA would also end the system of companies making money from selling insurance policies, i.e. it ends profit making. That is a reason for MfA that Bernie Sanders hammers at. He, with his brand of democratic socialism, believes generally that profit is the source of inequality but he also seems especially offended that companies profit from people’s health needs.

Elizabeth Warren, who might have been expected to support the ACA solution, given her general social democratic perspective, instead has come out strongly in favor of MfA. It seems that a key reason for her support of MfA is that continuing the ACA gives insurance companies too much profit and provides too much in executive salaries and administrative costs thereby absorbing monies that could otherwise be used for health care itself.

Indeed, as has been argued in one study: As tens of thousands of American families face bankruptcy and financial ruin because of the outrageously high cost of health care, and while 30 percent of U.S. adults with private health insurance delay seeking medical care each year due to cost, the top 65 healthcare CEOs made $1.7 billion in compensation in 2017, including $83.2 million for the CEO of United Health Group; $58.7 million for the CEO of Aetna and $43.9 million for the CEO of Cigna.

For comparison, the annual administrative costs of running the Medicare program average about 2% of its expenditures, while the administrative costs of private health insurance firms average more than 6 times as much, amounting to more than 12%. Indeed, the administrative costs of the U.S. health industry as a whole, including both private and public agencies, runs more than twice as high as that of the other advanced countries.

The point that the advocates of MfA make is that these funds are essentially wasted and instead could be devoted to providing better health care for all Americans.

5. Objections to MfA
Some people are simply cautious and don’t want to support something that departs too far from what they are used to. They tend also to think that MfA would make them change doctors, etc. when that is only a piece of propaganda. Indeed, all medical practitioners would be required under the MfA to accept MfA patients.

More potent as an objection is the thesis that MfA is a socialist program. It is not clearly so – it depends upon what socialism is. MfA is not classic socialism – the government will not be nationalizing insurance companies and becoming their owner. (Nor, of course, is it being proposed that the entire health care system be nationalized, i.e. that like the Veterans Administration here and the National Health Service in Britain, the public (the state) becomes the owner of every piece of the health care system – there is no slogan ‘V.A. for All’.) Rather, what is being proposed is more like the Interstate Highway System or the Post Office: an investment in a public good. (Of course, there are those who think that those entities are socialist!)

Buttigieg has a criticism of MfA that seems quite misguided. He has objected to both Sanders and Warren by claiming that because they do not offer a range of choices to people they are saying that it is “their way or the highway”. However, they are not asking to have it their way – they do think and argue that MfA is the best choice, but not because it is their choice but because the evidence bears them out that it is the best choice. That personal attack does not address the issue of whether MfA or ACA is the best choice for the country.

6. Can we afford to move to MfA?
Of course, we all know that the chief objection to MfA as our means of providing health insurance is how much the program would cost.

Those who defend this solution reject the idea that it would cost too much. Warren has recently released her plan for how to pay for MfA. A number of other studies have also been done. The bottom line is that we can indeed afford MfA. In fact, the truth is that we are already paying more than the cost of MfA for health care in the U.S.

That is, the general defense is clear: we already spent huge amounts on medical care and that money would go instead to paying for MfA. Those who look only at the cost of MfA, and not at the available funds that would be released by switching from our current system, are misrepresenting the situation. In fact, it is legitimate to claim that it might cost even less than we currently spend. Some of the evidence for that comes from a conservative source. “True, Medicare for All would increase federal health care spending. But that is not the same as increasing total health care spending, which was over $3.5 trillion last year. Instead, Medicare for All would move money from one column (private health insurance spending) to another (federal health spending); it does not automatically increase total costs. A recent study by the Mercatus Center at George Mason University — a free-market center generally hostile to government programs — estimates that for the 10 years between 2022 and 2031 the total national health costs for Senator Bernie Sanders’s Medicare for All plan would actually be $50.1 trillion. That would be $2 trillion less than if we let the system operate as it currently does.”

To provide a specific example of how MfA could be funded, we can examine the plan proposed by Warren, upon the advice of leading economists in the field. What she proposes is a combination of cost savings, revenue transfers and the creation of new revenue sources that would together replace most of the costs that are now borne by individuals and families and by small businesses. Taken together those revenue sources would successfully fund the expanded MfA program.

Specifically, Warren proposes among other items, that:
 The cost of pharmaceuticals would be cut by about 70% by requiring the federal government to bargain with the drug companies to get drug prices down to the levels paid by other nations, a savings of $1.7 trillion over the first decade.
 Another $1.8 trillion would be saved in administrative overhead cost as compared to what is now spent by the private insurance firms and by doctors and hospitals having to deal with the current array of insurers.
 An additional $2.9 trillion in savings would come from reorganizing how hospitals and medical practitioners are paid.
 A massive $8.8 trillion would come from requiring large, but not small, businesses to pay a fee to the Medicare system equivalent to 98% of what they now pay to private insurers.
 Under the new Medicare system, the costs for Medicaid for the poor and disabled that are now borne by state and local governments would be paid by the federal government. Those state and local funds would be required to be transferred to the Medicare system resulting in revenue of $6.1 trillion.

There would be, under Warren’s plan, no fees or taxes imposed on the poor or middle classes. Notice that her plan, in not having any additional taxes for the middle class, takes the most rigorous route possible – other versions of how to pay for MfA do not impose that stringent requirement on revenue: it is possible to support an MfA plan that does raise taxes on poor and middle class families but still maintains that the difference between the savings from the absence of premiums, co-pays and deductibles and the taxes levied would still leave families with more money than they now have.

On her plan, there would be no new taxes on the poor and middle class but a series of new taxes would be imposed upon large corporations and the rich, especially on very rich billionaires and millionaires. These new revenues would include among other items:
 Imposing new taxes on the capital gains received by people in the top 1% ($2 trillion)
 The wealth tax on billionaires would be increased from the 3% Warren already proposes (to be used for other new, non-medical programs) to 6% ($1 trillion).
 A new tax on financial stock transactions would be initiated ($0.8 trillion).
 Increasing the corporate tax rates that were recently cut ($2.9 trillion)
 Eliminate a Pentagon “overseas contingency fund” often criticized as a slush fund ($0.8 trillion)

The point is that when, for example Biden, and others, complain that MfA would cost $30 trillion over its first decade and claim that that is unreasonable and not feasible, they are simply misrepresenting the situation. The first misleading feature is using the figure for an entire decade instead of the yearly cost: the larger figure tends to stick in people’s minds; the yearly estimate would be of course $3 trillion. Secondly, the U.S., which is still (for now) the richest country in the world, indeed can afford to provide health insurance to all of its citizens just as every other developed nation does for theirs. Indeed, we can do so at less cost than we are now paying for what is an inadequate health care system. We can provide care for all and at a lower cost so that we no longer are forced to pay more than twice as much per person or as a percent of GDP than other nations which cover all of their people, while we have tens of millions without any health insurance.

A Major Objection to Accepting the MfA Solution
While the cost argument is the usual major objection to adopting MfA – and as I have just argued it does not hold water – there is another serious problem, not with the MfA itself but with any attempt to institute it in the here and now.

We of course have an existing health care system: the ACA. It relies upon private insurers and the mechanisms by which they provide insurance. If MfA were to be accepted and implemented, that system would be replaced. However, replacing it would cause truly significant problems, disruptive to both the economy generally and to the lives of many individuals.

Very many people who are currently employed by health insurance firms and people who work in medical offices doing the billing to these firms will be unemployed if MfA replaces the private insurance firms.

How many is “Very many”? At present there is no accepted estimate. There have been guesses that the number would be in the millions! There have been guesses that the number is less than that. At present, we do not know. All that can be said with certainly now is that a lot of people would lose their livelihood with the institution of MfA. Both their lives and the entire economy would be disrupted by the move to MfA.

It is not that this issue has entirely escaped the attention of those candidates and people who advocate MfA. In the MfA bill written by Sanders, and supported by Warren and others, there is a provision for a five billion dollar five-year program for transition assistance for workers displaced by the implementation of MfA; also in providing for a four-year phase-in process for MfA it would phase out those whose employment is dependent upon the current system rather than dumping them all at once into the ranks of the unemployed.

But, of course, that may not be enough money or time: those depend upon some estimate of how many would be effected and that number has not been well established so far.

Warren has recognized the possible enormity of the problem and is promising a major piece of work on the transition period. As of this writing, however, that necessary addition to the arguments has not yet been published. Until it is, until we have a good idea what the human and economic costs of the transition period will be, we cannot be whole-hearted advocates of the MfA solution. MfA may be in itself the best solution to the issue of health insurance for Americans but the effects of bringing it into being might be too great. That issue needs much more discussion than it is presently getting in the campaign.

X. A Final Concern
I said at the beginning that there are three different issues being addressed, more or less helter-skelter, in the health policy statements by the Democratic candidates for President. Those are, first and most importantly, how we Americans will be paying for our health care. Second, there is the issue of reducing our health care costs. Finally, there are also remarks in some of the candidates’ statements about how the country might (or might have to) change various matters about the delivery of health care itself.

I have only addressed the first issue above. So I will conclude with some very brief comments on the other two issues, issues that ought to be considered when Democrats evaluate their candidates on matters of health policy.

We pay more for our health care than any other industrialized nation, both in terms of amount spent and as a percentage of our GDP. The costs of health care are a serious problem. According to one study, 45 percent of Americans are worried a major illness could leave them bankrupt, 1 out of 4 Americans skipped needed medical care because they could not afford it, and 77 percent are concerned rising health costs will cause significant and last damage to our economy.

The aim of the Democratic Party is to reduce the amount of our medical expenditures to something roughly comparable to what those we compare ourselves with are paying.

The chief item that has engaged the candidates’ attention is the cost of prescription drugs. Today, about one out of every five Americans cannot afford to fill the prescriptions given to them by their doctors because we pay, by far, the highest price in the world for prescription drugs. Meanwhile, last year pharmaceutical companies made over $50 billion in profits. A 2013 study showed that in 2010, the United States paid, on average, about double what was paid in the United Kingdom, Australia and Switzerland for prescription drugs. Since 2014, the cost of 60 drugs commonly taken has more than doubled, and 20 of them have at least quadrupled in price.

We need to ask of our candidates what measures they recommend for lowering the price of prescription drugs. It is that issue that I am not pursuing here.

But the price of drugs is not the only cause of our high health care costs. There are matters such as how we (our insurance mostly) are billed for care: is there a set price for a certain procedure on the part of hospitals or medical practices or is the charge based on what can be wrung out of the insurance company or the individual payer? Are our medical practitioners paid too much especially when compared with the pay in comparable countries? Those (and others) are issues that need to be addressed in a Democratic approach to health care policy.

There is a final set of issues concerned with the quality of health care and its availability. Rural folk do not have the level of care that is found in urban centers. Also, why, for example, is our mortality rate for maternal care so high compared to our peers? Those kinds of issues can be found to be discussed in the candidates’ campaign statements. For example, under Warren’s plan the fees paid to hospitals and doctors in poor and rural areas are to be higher than the average in urban areas to attract and maintain services in those currently underserved areas. If we were to do a thorough job of seeing where our candidates stand on health policy, their ideas on improving the quality and availability of care for all Americans would also need to be discussed.