Racism, sexism, classism, greed and a poor understanding of who will be impacted. 5 reasons pretty much sums it up. You may when about sexism in that but women are poorer than men, are expected to pick up the burden of caring for elders and live longer than men. So the face of elder poverty is expendable women.
Because it takes your hard earned dollars and gives them to "those people. " When you talk about what motivates the Rs if you don't put race in the equation you are missing most of the story. These are the people who closed polls rather than integrate them.
Do they even understand that it is those in nursing homes and those receiving home care are receiving three-quarters of Medicaid payment outlays? Yet the bastards get on Fox and blather away about "single guys playing video games in Mum's basement" as those who are "draining the system". What is and what has been the real issue here is lack of strong messaging from Medicaid supporters about exactly who benefits and why, rather than playing defense and getting into mindless polemics regarding — wait for it —
"waste, fraud, and abuse".
As usual, the Right wins the propaganda battle, while the Left loses the public support war.
Maybe that $25 billion for rural hospitals will be so that they can hire clerical staff to help prospective & current patients fill out the forms correctly so as to receive Medicaid coverage.
As a single guy who does play video games a lot and doesn't have a formal job, I would like to object that I have private health insurance paid for by ACA subsidies, not Medicaid. 😆
They need something to cut and can't touch Social Security or Medicare for political reason. I assume they're being paid off by the insurance industry, so they don't touch Medicare Advantage.
Because they were raised to believe in individual initiative over collective responsibility? Somewhere in the Fifty’s anticommunist fright selfless sacrifice became a suspect trait, and empathy an undesirable marker of collectivist feelings.
It’s not for profit. They are free market fundamentalists who are deeply invested in the ridiculous idea that only the free market can give us quality products and services with good prices. Some really believe that, others just want to convince the public to let for profit companies run everything.
i think alot of people willing to gut medicaid do not believe in their hearts that the government should support those in need. survival of the fittest is their central totem. this is particularly strong in more rural white communities ? indigenous rural groups understand the need for government support, as inadequate as it is.
my family (my tribe) (my community) can handle this among ourselves privately (charity care run by private religious groups not the government) and everyone else does the same or suffers (or fies) unnecessarily from fixable medical issues. it is god's decision who suffers, not me.
i have never been able to have these people understand that our entire current society depends technological progress and it is driven by the goal of all of us having better and better minimum standards and quality of life. it works today through consumerism and public institutions.
as individuals we collectively pay for all this (GDP) during our working years. as children, the accident of birth accounts for too much and our post working retirements are fraught with the spector of death or impoverishment.
My question was rather tongue in cheek rhetorical because I know the answer. Like you say, there are sadly a large number of people out there who believe they are better/more entitled than everyone else. They fail to learn the lessons of history that the type of society they crave inevitably leads to such inequality and repression that they end in revolution. “Let them eat cake”…
I think your first two paras are on the spot. But then the same people (and others) come and ask for their "pork" and usually get it at the expense of the lesser well off. It's the "me first" US system; in a way it's democracy, except for the distortions in the representative system a commentator mentioned, electoral system, 2 senators for each state, gerrymandering, etc
Don't tune out at the endless discussion of the minutiae of health care. The discussion ends up on science, which is a lot easier to understand. And probably a lot more important. The message is that the Trump Gang is killing the goose that laid the golden egg: American science.
My biggest fear is Trump's 150 billion (not ONLY 45 like I wrote earlier) ICE money. I'm afraid it will be his own private army and that immigrants will be forced to live in squalor on the tax payer's dollar while security/detention center companies will make a load of money. And that immigrants will be forced to work at close to if not at slave labor for corporations, and that any dissenters, including US citizens, could be at great risk very shortly.
That's the alarm being sounded by some.
Thank you for this post on medical coverage. You always go to the top expert which makes your information the most relevant.
Ironic that his ending quip targets the Tea Party... That movement fought Obama on his ICE expansions, which provided the legal basis for everything Trump is arguing now.
One likely possibility: Giving $138B to this agency, when they (only) have $11B now, is a financial recipe for disaster. Whenever people or agencies get an order of magnitude more $$, they have no clue or any experience in how to handle it. They have the thought they now have a bottomless pit of cash and so they can do ANYTHING. And so they try. Chaos and corruption quickly follow. Mayhem is the outcome. It all becomes a massive disaster.
You talk about volunteers to reach out to assist people through the Medicare/Medicaid maze. Although it is underfunded, grossly underpublicized and does not go out door-to-door, the program already exists. I am a SHIP counselor (State Health Insurance Assistance Program). SHIP (called by different names in some states) is a nationwide program of federally trained and certified volunteers who counsel people about Medicare and Medicaid options. Unlike insurance brokers, we do not receive commissions from insurance companies for signing people up, so we have no financial bias other than the welfare of the consumer. The initial budget proposals zeroed out SHIP (of course), but it somehow came back and survived intact. It is a small bulwark against what is happening - but it is a bulwark and needs to get promoted at every opportunity.
As a gig economy worker, I am wondering if incorporating and paying myself a salary is a way to make reporting requirements less difficult. My coworkers are completely freaking out.
I am afraid Gruber is wrong in his closing optimism. Ever since Lyndon Johnson decided to increase U.S. involvement in Vietnam, I have felt that the U.S. was moving almost linearly in the wrong direction and always thought that the pendulum would swing beck in a more positive direction. I believed that Richard Nixon was the worst thing imaginable, but by comparison with politics today, he looks positively liberal. Reagan still look awful and was the beginning of the movement toward more and more selfish, conservative attitudes in voters. Americans now are being divided into haves and have-nots where the almost-haves are afraid of losing what little bit of wealth they have and are willing to take away what little is provided to the have-nots.. After nearly 50 years of seeing this in the U.S. and being politically active, I left and am now a citizen of Canada approaching my 90th year and increasingly glad that I made the decision to move across the boarder. I share the distaste of most Canadians with the actions of the U.S. Government that is supported by American voters. Things are not going to get better in the U.S. It is going to get worse.
"The problem with universal healthcare is that people don't want to give up their insurance for some nebulous Berniecare." Spot on. If you ask Americans if they approve of universal healthcare, 70% say yes. But if you ask the follow-up question "You realize this means you too?" then support drops in half, to 35%.
The answer is straightforward. Legislation that would require corporations to offer Medicare as an option to their employees. This would cost the employer the going rate, say $6,000, so no-one can complain that corporations are getting government handouts. Moreover, 1) no senior already on Medicare could complain that "they worked for it," and 2) those employees who want to remain on their private insurance would be free to do so.
Medicare would also be available to the self-employed.
Such a system would save $1 trillion per year, something the corporations would support - see our 2019 book "Healing American Healthcare."
The ACA may be a 3-legged stool - and therefore vulnerable - but is overly complex, and has left 70 million Americans either uninsured or under-insured.
US Corporations should support some form of single payer system just so that they can get out of being part of managing the complex nightmare that is the US heath insurance system. Companies in no other country are mired in anything like this mess. Getting rid of the hassle would probably allow corporations to sack a 10th of their HR staff, possibly more. As a bribe to the workers, companies could increase pay by the same amount that they currently contribute toward the employees heath insurance.
Actually, I read today that it's just the opposite. There's talk about charging launch companies up to $30,000 per launch. I also read that at least one of the European countries is working on the infrastructure to be able to launch their own satellites.
Even Bernie pointed out the cost benefit to business with a universal health plan and yes Tesla will take a hit with the loss of the EV subsidies, but so will the big 3. I did not know Musk as advocating for them as well as himself and Tesla. I don't do X or social media, so I am not up to date on everything Musk.
This is a win-win for the citizen and also for the corporations. Of course, it will be vigorously opposed by the insurance industry, but this would not be a big deal. The insurance industry is reviled by most Americans.
Yes. Corporate structure enables paying the corner-office executives 500 times more than the average employee. Even JP Morgan famously thought that was an exceedingly bad idea.
Actually, Medicaid is far more cost effective than Medicare based on past research.
A buy-in to Medicaid should be the public option priced at a certain percentage of any income over the qualifying poverty limit.
This would allow people to keep it even as they begin to make more money. They would simply pay a percentage to keep it.
People on Medicare should be allowed to choose the buy-in Medicaid option, as well, instead.
Medicare is now very expensive. I took a huge hit to my wallet when I had to trade my subsidized ACA plan for Medicare when I turned 65 - yikes!
I know low-income seniors have some options, but I want to be able to leave something to my kids and not have to worry about state Medicaid estate recovery issues where they can then take your house when you die simply because you were poor enough to need Medicaid assisted living at some stage. Odd that a supposedly liberal state like CA still does that to people. They also allow hospitals to be exempt in a bankruptcy and allow them to not exclude your home in CA, so you can lose it if you have large medical bills
Tip- if you are running for governor next time, promise to fix all of that as well as undo some of the parent to child and grandchild changes so we can not be so stressed that all one worked for will all be taken away due to illness.
Anyway, with a buy-in higher earners they may decide that X percentage of income to buy in to Medicaid is more expensive than a regular policy and switch, so it would still cover mostly the average and lower income workers who decide to buy-in or who qualify based on income.
The reasoning behind requiring you to spend down your assets like your house is that other taxpayers who may be poorer than you are helping pay for your care. Requiring younger taxpayers and people who don’t have enough net income after taxes to pay for their family living expenses, let alone buy a house, to subsidize the estates of older people is inequitable.
I'm not talking about that. I am talking about estate recovery after you die if you go into a nursing home on Medicaid. They can take the house and other assets to pay for your care. Many states do this.
Sounds like you have a high income. Medicare is essentially free to middle and low income people over the age of 65. Think of it like a tax. In other wealthy countries, medical provision is taken out of income taxes and everyone understands this. Even in the US, if you have employer-based insurance, this is not free because your corporation is not a charity, so your income is lowered by the amount of the cost of the healthcare they provide (there is no free lunch).
The problem with Medicaid is that most doctors don't take it. So, you get what you pay for.
Sounds like you have never bothered to even look up the cost of Medicare or what it does or does not cover.
Please look it up. Just the base insurance is over 2200 a year and that does not cover prescription drugs or gap insurance and there are yearly caps and no out of pocket min based on income like the aca has
if you apply for QMB it can bump you into Medicaid and then the state can take your home when you die. not worth it.
Medicaid covers far more even if fancy places like Mayo Clinic don't take it, but despite your claims enough drs do but they have to get rid of estate recovery
There's another simple solution: raise taxes on the wealthy and give everyone access to Medicare. It's how it's done in other wealthy countries. Why should any citizen of the richest country in the world have to put up with Medicaid?
Medicaid has no deductibles and no out of pocket costs, no medical bills at all, no surprise bills, so why would anyone put up with Medicare that does not always cover everything? People can go bankrupt even on Medicare, but not Medicaid. The problem is the estate recovery where Medicaid will hijack your estate when you die and take your house - that is if you end up in nursing care and live in certain states like CA.
Medicaid is very good, better than Medicare. No copay, no deductible, covered all my medications for free, and were reasonable when my doctor had to prescribe something that my current insurance doesn't even have in their formulary.
WoW....CA must want the elderly to get out of state & make room for more young tech people! My mom was affluent, but she lived debt-free in rural midwest on her $10,000+/- annual social security income that didn't take THAT much out for Medicare! And she never paid out of pocket. Of course, her then available Plan F annual premiums were $5,000, Plan D premiums were worth it--as she was diabetic with minor cardiovascular issues, and she did pay for a long-term care plan out of her investment income. She was in assisted living for four years due to mobility and memory issues with taking her meds. She spent the last 60+ days of her life between the hospital and in skilled nursing covered completely by Medicare. She would have been happier to have unconsciously passed away during her diabetic episode, rather than those last miserable 60+ days. Staff need to be observant of dietary intake when administering diabetic meds.
My Medicare payments are $82.50/month. They are that high only because I was late signing up when I turned 65. My bill every month contains a note that part of the bill is a charge for delayed signup.
All of these discussions are very informative. Depressing, but informative. However, they're missing the elephant standing in the middle of the hospital lobby, so to speak. The elephant is costs. Absent huge, apparently politically impossible, changes in the US system, specifically reducing the parasitic drag of the insurance industry, and ending the capture of Congress by the pharmaceutical industry, the US will be bled to death by health care expenses. The US wastes about $2trillion/yr on health care, spending about twice per capital what other counties do. This money effectively dissapears, not making any contributions to US innovation, production, education, or anything else. Beyond the direct costs, by tying down armies of fairly clever people to run the Byzantine system, you've even lost out on potentially productive work they could otherwise be doing. There are groups of people in health insurance companies working day and night to figure out optimal ways of denying your claims; surely there's something more useful for them to be doing?
Excellent discussion - thank you both. Prof. Grueber said yes, he thinks the political party responsible will face consequeces, but if these cuts don't really kick in until AFTER the mid-terms (how convenient), it won't be soon enough. Also, I read yesterday that about 2/3 of voters said they 'hadn't heard about the bill'. Were they living on another planet?? That's almost ALL I've seen and heard.
I'm currently reading Evan Osnos' 'Haves and Have Yachts', which partially answers Prof. Grueber's comment about Josh Hawley and his cohorts. Almost, if not all, Senators are millionaires, if not billionaires. They won't ever need Medicaid, or any other type of public help. Therefore they literally can't conceive of the lives of people who DO need it. It's the worst case of "let them eat cake" I've ever seen.
What about a state like Virginia where the GOP put a ticking time bomb in our Medicaid expansion? If the feds reduce their contribution, the program in Virginia ends. How ironic that the party that screams about over regulation in order to appeal to small business owners is using excessive regulation and paperwork to kill healthcare?
Out hiking yesterday, the idea of making every Democratic party office a hub for aiding those unable to navigate the deliberately obstructionist regulations. Provide transport, coffee and donuts, and volunteers or paid help to get the victims of Republican policy in the door. They'll never forget it. This is a huge opportunity for Democrats to show compassion and humanity.
I'm a retired academic (tax accounting) and associate dean of a business school. All undergraduate business majors had to do a 3-credit, letter grade, semester long, internship course. It could be paid or volunteer, but it had to be related to the student 's major (junior or senior years), and a faculty member is each department served as the supervisor; this counted as a course for the faculty member. There are universities, colleges and community colleges almost everywhere. If schools set up an internship program whereby students could volunteer to be trained in helping people sign up for and report to Medicaid and SNAPP think of the possibilities. It would not only help the public but it would help the students learn about a side of life that they may not be familiar with. It would be a constant supply of helpers. It's difficult to get people to come to a campus, parking is often horrid and buses may be unreliable, but schools could partner with churches, synagogues and temples, as well as community centers, to hold clinics. They could Zoom with people to walk them through the processes. I supervised VITA (Volunteer Income Tax Assistance) programs through the IRS and law schools do legal clinics for the public so I know it can be done. I'd also recommend the research done by the political scientist Don Moynihan (who also has a Substack) dealing with administrative burden. He's done a lot of work with what helps and what hinders.
This is well reasoned. When I lived in CT, the senior center used volunteers--other seniors-- to help seniors sign up for various programs like winter heat aid.
I particularly appreciate the suggestion regarding administrative burden research. From my experience as a medical social worker for a large county, I suggest that whatever department administers Medicaid in a particular state will have to add staff to handle the burden of twice-a-year redetermination. In the long run, there will cost savings only insofar as people are dumped off Medicaid due to administrative issues.
Zoom may not work for the poorest people unless they have surplus minutes on their smartphones (provided for free by Lifeline). And in large rural counties with poor public transportation like mine in SC, even getting to a community center may be difficult during the week, especially with work requirements.
This needs many comments from someone who worked as a doctor:
Regarding the cited Mexican system: This is really the UK model for much specialty care and some primary care. It is a two-tier system, and the higher levels of physician income come from having a private practice. Note, as an example of this, Kate did not have the royal children at a NHS hospital.
The impact of the BBB will be found ultimately in population-based death rates, and the effects will likely take 2 to 5 years really to be seen. Even if state vital statistics offices are made less functional (witness FL for this), sources online, such as legacy.com can be scraped by AI for data.
Those Medicaid re-determination forms will depend on medical data. One can only hope that electronic health record vendors will adjust their systems to facilitate providing the data. Such reprogramming takes time, which will be the problem. I have done re-determination forms for a relative who had profound medical problems, but the regs required the forms once a year, even when the patient had zero chance of improving (bad Parkinson disease). For forms are a morass, even for someone who has done such documentation for decades. For the average person, the forms are a guaranteed failure. Hello, massive disenrollment.
With disenrollment comes not just loss of insurance. It is the chaos of a system that devolves to the ER, and with such a system, transfer to skilled care facilities bogs down, leading to longer and frustrating acute care hospitalization and a lack of beds. Look at the first episode of "The Pitt" where the administrator hassles the chief doctor over this exact problem, as though he could fix it. The result of all this is provider burnout.
The economic modeling of healthcare suffers, because everyone ignores the reality that the money is not spent by the beneficiary (patient) nor by the provider hospital or healthcare system (they bill for services, but they, as are private insurance, are beneficiaries and intermediaries). The expenditure depends on the actions and documentation from a physician or non-physician provider (PA or nurse practitioner, for example). No one really understands how this happens, and no one really understands what the value is and how value is really derived from the work and other expenditure in providing healthcare. No one is paying attention to what waste really is, although Republicans certainly love to talk about it and can't quantitate it with any data. In a sense, the inverse of waste is value, and that also remains difficult to define and to quantitate.
What I hope for, but will likely never happen, is for the doctors in this country to awaken and react. Docs are the sleeping giant here. Will they start to tell the likes of RFK that he and his bosses have gone too far?
The vaste majority of doctors in Britain work for the NHS. Many consultants run private clinics on the side but it's a usually a supplementary source of income.
Actually, Prince George and his siblings were INDEED born in an NHS hospital: St Mary’s Paddington, which actually happens to be my local hospital. Despite the NHS being a bit of a behemoth (I’m Australian and prefer the Mutual Benefit systems there and in Belgium, which is fairer and more effective than « everyone pays nothing, even if they earn a lot »), I’ve had just brilliant care at St Mary’s over the years… even though I was a low-paid public servant. My care was free. And yes, from Harley Street surgeons, who all put in stacks of time (and care) working for the NHS. There is a reason it is so dear to the heart of the British…
Can you please explain to me WHY Republicans hate Medicaid so much? Is that a failure of basic human decency?
Racism, sexism, classism, greed and a poor understanding of who will be impacted. 5 reasons pretty much sums it up. You may when about sexism in that but women are poorer than men, are expected to pick up the burden of caring for elders and live longer than men. So the face of elder poverty is expendable women.
Because it takes your hard earned dollars and gives them to "those people. " When you talk about what motivates the Rs if you don't put race in the equation you are missing most of the story. These are the people who closed polls rather than integrate them.
Because they are selfish
In a word, yes, selfish serves as a complete answer.
Do they even understand that it is those in nursing homes and those receiving home care are receiving three-quarters of Medicaid payment outlays? Yet the bastards get on Fox and blather away about "single guys playing video games in Mum's basement" as those who are "draining the system". What is and what has been the real issue here is lack of strong messaging from Medicaid supporters about exactly who benefits and why, rather than playing defense and getting into mindless polemics regarding — wait for it —
"waste, fraud, and abuse".
As usual, the Right wins the propaganda battle, while the Left loses the public support war.
Maybe that $25 billion for rural hospitals will be so that they can hire clerical staff to help prospective & current patients fill out the forms correctly so as to receive Medicaid coverage.
Single guys playing video games all day instead of working—the WSJ had an editorial saying that this describes millions of Medicaid recipients.
Further millions are said to be illegal migrants.
The MAGAs in the comments were going nuts.
As a single guy who does play video games a lot and doesn't have a formal job, I would like to object that I have private health insurance paid for by ACA subsidies, not Medicaid. 😆
No criticism intended. My son was always big on video games.
I’m happy to live in Canada where everyone gets healthcare paid by our taxes. No one has to qualify.
There are plenty of times I wish I was Canadian. Or Swedish.
I appreciate that more than anything. Healthcare should be for everyone. You shouldn’t have to jump through hoops to get it (or be wealthy).
The GOP is stuck in the "welfare queen" mentality of the 1980's. They "lift" themselves by putting and keeping others down.
They need something to cut and can't touch Social Security or Medicare for political reason. I assume they're being paid off by the insurance industry, so they don't touch Medicare Advantage.
Yes.
Because they were raised to believe in individual initiative over collective responsibility? Somewhere in the Fifty’s anticommunist fright selfless sacrifice became a suspect trait, and empathy an undesirable marker of collectivist feelings.
Because it predominately benefits "those" people.
Yes
It’s not for profit. They are free market fundamentalists who are deeply invested in the ridiculous idea that only the free market can give us quality products and services with good prices. Some really believe that, others just want to convince the public to let for profit companies run everything.
i think alot of people willing to gut medicaid do not believe in their hearts that the government should support those in need. survival of the fittest is their central totem. this is particularly strong in more rural white communities ? indigenous rural groups understand the need for government support, as inadequate as it is.
my family (my tribe) (my community) can handle this among ourselves privately (charity care run by private religious groups not the government) and everyone else does the same or suffers (or fies) unnecessarily from fixable medical issues. it is god's decision who suffers, not me.
i have never been able to have these people understand that our entire current society depends technological progress and it is driven by the goal of all of us having better and better minimum standards and quality of life. it works today through consumerism and public institutions.
as individuals we collectively pay for all this (GDP) during our working years. as children, the accident of birth accounts for too much and our post working retirements are fraught with the spector of death or impoverishment.
My question was rather tongue in cheek rhetorical because I know the answer. Like you say, there are sadly a large number of people out there who believe they are better/more entitled than everyone else. They fail to learn the lessons of history that the type of society they crave inevitably leads to such inequality and repression that they end in revolution. “Let them eat cake”…
It's not that they fail to learn the lessons of history so much as it is they have psychopathic tendencies - which includes sadism.
Ok that’s getting a touch extreme now.
But is it?
They voted for someone who said "I could shoot someone on Fifth Avenue and still get elected!" Who but a psychopath would even >think< such a thing?
Who would vote for someone like that and who also promised cruelty to the most vulnerable citizens?
Honestly, for many it seems to be “survival of the richest,” mixed with “survival of the whitest.”
I think your first two paras are on the spot. But then the same people (and others) come and ask for their "pork" and usually get it at the expense of the lesser well off. It's the "me first" US system; in a way it's democracy, except for the distortions in the representative system a commentator mentioned, electoral system, 2 senators for each state, gerrymandering, etc
Don't tune out at the endless discussion of the minutiae of health care. The discussion ends up on science, which is a lot easier to understand. And probably a lot more important. The message is that the Trump Gang is killing the goose that laid the golden egg: American science.
Actually, he's killing America itself.
My biggest fear is Trump's 150 billion (not ONLY 45 like I wrote earlier) ICE money. I'm afraid it will be his own private army and that immigrants will be forced to live in squalor on the tax payer's dollar while security/detention center companies will make a load of money. And that immigrants will be forced to work at close to if not at slave labor for corporations, and that any dissenters, including US citizens, could be at great risk very shortly.
That's the alarm being sounded by some.
Thank you for this post on medical coverage. You always go to the top expert which makes your information the most relevant.
It's even worse than that - 150 billion. And you're right, it's to create a "Neu Gestapo".
Thanks for correcting me.
He already has his "brownshirts."
Indeed he does! And he's about to get a lot more of them. This Big Atrocity of a Bill gives 150 billion to ICE. It's really, really, appalling.
Ironic that his ending quip targets the Tea Party... That movement fought Obama on his ICE expansions, which provided the legal basis for everything Trump is arguing now.
One likely possibility: Giving $138B to this agency, when they (only) have $11B now, is a financial recipe for disaster. Whenever people or agencies get an order of magnitude more $$, they have no clue or any experience in how to handle it. They have the thought they now have a bottomless pit of cash and so they can do ANYTHING. And so they try. Chaos and corruption quickly follow. Mayhem is the outcome. It all becomes a massive disaster.
Republicans thrive on promoting bad governance, then campaigning on government disfunction.
You talk about volunteers to reach out to assist people through the Medicare/Medicaid maze. Although it is underfunded, grossly underpublicized and does not go out door-to-door, the program already exists. I am a SHIP counselor (State Health Insurance Assistance Program). SHIP (called by different names in some states) is a nationwide program of federally trained and certified volunteers who counsel people about Medicare and Medicaid options. Unlike insurance brokers, we do not receive commissions from insurance companies for signing people up, so we have no financial bias other than the welfare of the consumer. The initial budget proposals zeroed out SHIP (of course), but it somehow came back and survived intact. It is a small bulwark against what is happening - but it is a bulwark and needs to get promoted at every opportunity.
As a gig economy worker, I am wondering if incorporating and paying myself a salary is a way to make reporting requirements less difficult. My coworkers are completely freaking out.
I am afraid Gruber is wrong in his closing optimism. Ever since Lyndon Johnson decided to increase U.S. involvement in Vietnam, I have felt that the U.S. was moving almost linearly in the wrong direction and always thought that the pendulum would swing beck in a more positive direction. I believed that Richard Nixon was the worst thing imaginable, but by comparison with politics today, he looks positively liberal. Reagan still look awful and was the beginning of the movement toward more and more selfish, conservative attitudes in voters. Americans now are being divided into haves and have-nots where the almost-haves are afraid of losing what little bit of wealth they have and are willing to take away what little is provided to the have-nots.. After nearly 50 years of seeing this in the U.S. and being politically active, I left and am now a citizen of Canada approaching my 90th year and increasingly glad that I made the decision to move across the boarder. I share the distaste of most Canadians with the actions of the U.S. Government that is supported by American voters. Things are not going to get better in the U.S. It is going to get worse.
Great interview. Thanks for the transcript !
"The problem with universal healthcare is that people don't want to give up their insurance for some nebulous Berniecare." Spot on. If you ask Americans if they approve of universal healthcare, 70% say yes. But if you ask the follow-up question "You realize this means you too?" then support drops in half, to 35%.
The answer is straightforward. Legislation that would require corporations to offer Medicare as an option to their employees. This would cost the employer the going rate, say $6,000, so no-one can complain that corporations are getting government handouts. Moreover, 1) no senior already on Medicare could complain that "they worked for it," and 2) those employees who want to remain on their private insurance would be free to do so.
Medicare would also be available to the self-employed.
Such a system would save $1 trillion per year, something the corporations would support - see our 2019 book "Healing American Healthcare."
The ACA may be a 3-legged stool - and therefore vulnerable - but is overly complex, and has left 70 million Americans either uninsured or under-insured.
US Corporations should support some form of single payer system just so that they can get out of being part of managing the complex nightmare that is the US heath insurance system. Companies in no other country are mired in anything like this mess. Getting rid of the hassle would probably allow corporations to sack a 10th of their HR staff, possibly more. As a bribe to the workers, companies could increase pay by the same amount that they currently contribute toward the employees heath insurance.
Yes, US companies having to foot the bill for insurance premiums puts them at a disadvantage when competing globally.
Also, did anyone realize that Trump just doomed the auto industry that has made a lot of investments to produce EVs by axing the subsidies?
yes. so did musk. old news.
Actually, MuskRat was - and is - totally dependent on those subsidies.
exactly what I was saying. that's one of the reasons he hated the bill. though I guess there's a space travel tax break somewhere in there.
He's been trying to get one, but he might soon be begging to just not be deported.
Actually, I read today that it's just the opposite. There's talk about charging launch companies up to $30,000 per launch. I also read that at least one of the European countries is working on the infrastructure to be able to launch their own satellites.
Even Bernie pointed out the cost benefit to business with a universal health plan and yes Tesla will take a hit with the loss of the EV subsidies, but so will the big 3. I did not know Musk as advocating for them as well as himself and Tesla. I don't do X or social media, so I am not up to date on everything Musk.
Without those subsidies, nobody would ever have known who MuskRat is. He'd be a dead broke nobody.
paypal
This is a win-win for the citizen and also for the corporations. Of course, it will be vigorously opposed by the insurance industry, but this would not be a big deal. The insurance industry is reviled by most Americans.
Face it, today the medical & insurance industrial complex is the MAJORITY industry in much of the country.
"...companies could increase pay by the same amount..." ha ha ha, that'll never happen! They'd rather pocket it for themselves!
Yes. Corporate structure enables paying the corner-office executives 500 times more than the average employee. Even JP Morgan famously thought that was an exceedingly bad idea.
Actually, Medicaid is far more cost effective than Medicare based on past research.
A buy-in to Medicaid should be the public option priced at a certain percentage of any income over the qualifying poverty limit.
This would allow people to keep it even as they begin to make more money. They would simply pay a percentage to keep it.
People on Medicare should be allowed to choose the buy-in Medicaid option, as well, instead.
Medicare is now very expensive. I took a huge hit to my wallet when I had to trade my subsidized ACA plan for Medicare when I turned 65 - yikes!
I know low-income seniors have some options, but I want to be able to leave something to my kids and not have to worry about state Medicaid estate recovery issues where they can then take your house when you die simply because you were poor enough to need Medicaid assisted living at some stage. Odd that a supposedly liberal state like CA still does that to people. They also allow hospitals to be exempt in a bankruptcy and allow them to not exclude your home in CA, so you can lose it if you have large medical bills
Tip- if you are running for governor next time, promise to fix all of that as well as undo some of the parent to child and grandchild changes so we can not be so stressed that all one worked for will all be taken away due to illness.
Anyway, with a buy-in higher earners they may decide that X percentage of income to buy in to Medicaid is more expensive than a regular policy and switch, so it would still cover mostly the average and lower income workers who decide to buy-in or who qualify based on income.
The reasoning behind requiring you to spend down your assets like your house is that other taxpayers who may be poorer than you are helping pay for your care. Requiring younger taxpayers and people who don’t have enough net income after taxes to pay for their family living expenses, let alone buy a house, to subsidize the estates of older people is inequitable.
I'm not talking about that. I am talking about estate recovery after you die if you go into a nursing home on Medicaid. They can take the house and other assets to pay for your care. Many states do this.
Is healthcare a right or not?
https://www.dhcs.ca.gov/services/Pages/TPLRD_ER_cont.aspx
Sounds like you have a high income. Medicare is essentially free to middle and low income people over the age of 65. Think of it like a tax. In other wealthy countries, medical provision is taken out of income taxes and everyone understands this. Even in the US, if you have employer-based insurance, this is not free because your corporation is not a charity, so your income is lowered by the amount of the cost of the healthcare they provide (there is no free lunch).
The problem with Medicaid is that most doctors don't take it. So, you get what you pay for.
https://www.dhcs.ca.gov/services/Pages/TPLRD_ER_cont.aspx
if your income is too low applying for QMB can also put you on medicaid
Free?
Sounds like you have never bothered to even look up the cost of Medicare or what it does or does not cover.
Please look it up. Just the base insurance is over 2200 a year and that does not cover prescription drugs or gap insurance and there are yearly caps and no out of pocket min based on income like the aca has
if you apply for QMB it can bump you into Medicaid and then the state can take your home when you die. not worth it.
Medicaid covers far more even if fancy places like Mayo Clinic don't take it, but despite your claims enough drs do but they have to get rid of estate recovery
There's another simple solution: raise taxes on the wealthy and give everyone access to Medicare. It's how it's done in other wealthy countries. Why should any citizen of the richest country in the world have to put up with Medicaid?
Medicaid has no deductibles and no out of pocket costs, no medical bills at all, no surprise bills, so why would anyone put up with Medicare that does not always cover everything? People can go bankrupt even on Medicare, but not Medicaid. The problem is the estate recovery where Medicaid will hijack your estate when you die and take your house - that is if you end up in nursing care and live in certain states like CA.
Medicaid is very good, better than Medicare. No copay, no deductible, covered all my medications for free, and were reasonable when my doctor had to prescribe something that my current insurance doesn't even have in their formulary.
WoW....CA must want the elderly to get out of state & make room for more young tech people! My mom was affluent, but she lived debt-free in rural midwest on her $10,000+/- annual social security income that didn't take THAT much out for Medicare! And she never paid out of pocket. Of course, her then available Plan F annual premiums were $5,000, Plan D premiums were worth it--as she was diabetic with minor cardiovascular issues, and she did pay for a long-term care plan out of her investment income. She was in assisted living for four years due to mobility and memory issues with taking her meds. She spent the last 60+ days of her life between the hospital and in skilled nursing covered completely by Medicare. She would have been happier to have unconsciously passed away during her diabetic episode, rather than those last miserable 60+ days. Staff need to be observant of dietary intake when administering diabetic meds.
My Medicare payments are $82.50/month. They are that high only because I was late signing up when I turned 65. My bill every month contains a note that part of the bill is a charge for delayed signup.
"In 2025, the standard monthly premium for Medicare Part B (Medical Insurance) is $185. "
Maybe it depended on when you turned 65?
All of these discussions are very informative. Depressing, but informative. However, they're missing the elephant standing in the middle of the hospital lobby, so to speak. The elephant is costs. Absent huge, apparently politically impossible, changes in the US system, specifically reducing the parasitic drag of the insurance industry, and ending the capture of Congress by the pharmaceutical industry, the US will be bled to death by health care expenses. The US wastes about $2trillion/yr on health care, spending about twice per capital what other counties do. This money effectively dissapears, not making any contributions to US innovation, production, education, or anything else. Beyond the direct costs, by tying down armies of fairly clever people to run the Byzantine system, you've even lost out on potentially productive work they could otherwise be doing. There are groups of people in health insurance companies working day and night to figure out optimal ways of denying your claims; surely there's something more useful for them to be doing?
One informative graphic novel on its way!
Thanks to you both. Obviously this topic is badly in need of clarification, and you have done a fabulous job here.
Arriving in today's mail!
Thank you for the heads-up, all!
Excellent discussion - thank you both. Prof. Grueber said yes, he thinks the political party responsible will face consequeces, but if these cuts don't really kick in until AFTER the mid-terms (how convenient), it won't be soon enough. Also, I read yesterday that about 2/3 of voters said they 'hadn't heard about the bill'. Were they living on another planet?? That's almost ALL I've seen and heard.
I'm currently reading Evan Osnos' 'Haves and Have Yachts', which partially answers Prof. Grueber's comment about Josh Hawley and his cohorts. Almost, if not all, Senators are millionaires, if not billionaires. They won't ever need Medicaid, or any other type of public help. Therefore they literally can't conceive of the lives of people who DO need it. It's the worst case of "let them eat cake" I've ever seen.
What about a state like Virginia where the GOP put a ticking time bomb in our Medicaid expansion? If the feds reduce their contribution, the program in Virginia ends. How ironic that the party that screams about over regulation in order to appeal to small business owners is using excessive regulation and paperwork to kill healthcare?
Out hiking yesterday, the idea of making every Democratic party office a hub for aiding those unable to navigate the deliberately obstructionist regulations. Provide transport, coffee and donuts, and volunteers or paid help to get the victims of Republican policy in the door. They'll never forget it. This is a huge opportunity for Democrats to show compassion and humanity.
I'm straining, unsuccessfully, to extract the promised "not as depressing as you might think" from this article.
John McCain was from a state that had already expanded Medicaid even before the ACA and it was/is a very good program.
They did it by voter initiative, if I recall.
So, he knew what the people of his state wanted and the ACA gave his state more money to keep this program going.
I bet McConnell knew he would be a "no" and was counting on it because they have nothing to replace it with.
Even now, the GOP have postponed the Medicaid cuts until after the midterms because they know it would doom them.
Not only would it doom them in the midterms, if the Dems take the midterms anyway, the Reps can blame the whole thing on them.
"In 2025, the standard monthly premium for Medicare Part B (Medical Insurance) is $185. "
Maybe it depended on when you turned 65?
I'm a retired academic (tax accounting) and associate dean of a business school. All undergraduate business majors had to do a 3-credit, letter grade, semester long, internship course. It could be paid or volunteer, but it had to be related to the student 's major (junior or senior years), and a faculty member is each department served as the supervisor; this counted as a course for the faculty member. There are universities, colleges and community colleges almost everywhere. If schools set up an internship program whereby students could volunteer to be trained in helping people sign up for and report to Medicaid and SNAPP think of the possibilities. It would not only help the public but it would help the students learn about a side of life that they may not be familiar with. It would be a constant supply of helpers. It's difficult to get people to come to a campus, parking is often horrid and buses may be unreliable, but schools could partner with churches, synagogues and temples, as well as community centers, to hold clinics. They could Zoom with people to walk them through the processes. I supervised VITA (Volunteer Income Tax Assistance) programs through the IRS and law schools do legal clinics for the public so I know it can be done. I'd also recommend the research done by the political scientist Don Moynihan (who also has a Substack) dealing with administrative burden. He's done a lot of work with what helps and what hinders.
This is well reasoned. When I lived in CT, the senior center used volunteers--other seniors-- to help seniors sign up for various programs like winter heat aid.
I particularly appreciate the suggestion regarding administrative burden research. From my experience as a medical social worker for a large county, I suggest that whatever department administers Medicaid in a particular state will have to add staff to handle the burden of twice-a-year redetermination. In the long run, there will cost savings only insofar as people are dumped off Medicaid due to administrative issues.
Zoom may not work for the poorest people unless they have surplus minutes on their smartphones (provided for free by Lifeline). And in large rural counties with poor public transportation like mine in SC, even getting to a community center may be difficult during the week, especially with work requirements.
I think that is a BRILLIANT idea.
This needs many comments from someone who worked as a doctor:
Regarding the cited Mexican system: This is really the UK model for much specialty care and some primary care. It is a two-tier system, and the higher levels of physician income come from having a private practice. Note, as an example of this, Kate did not have the royal children at a NHS hospital.
The impact of the BBB will be found ultimately in population-based death rates, and the effects will likely take 2 to 5 years really to be seen. Even if state vital statistics offices are made less functional (witness FL for this), sources online, such as legacy.com can be scraped by AI for data.
Those Medicaid re-determination forms will depend on medical data. One can only hope that electronic health record vendors will adjust their systems to facilitate providing the data. Such reprogramming takes time, which will be the problem. I have done re-determination forms for a relative who had profound medical problems, but the regs required the forms once a year, even when the patient had zero chance of improving (bad Parkinson disease). For forms are a morass, even for someone who has done such documentation for decades. For the average person, the forms are a guaranteed failure. Hello, massive disenrollment.
With disenrollment comes not just loss of insurance. It is the chaos of a system that devolves to the ER, and with such a system, transfer to skilled care facilities bogs down, leading to longer and frustrating acute care hospitalization and a lack of beds. Look at the first episode of "The Pitt" where the administrator hassles the chief doctor over this exact problem, as though he could fix it. The result of all this is provider burnout.
The economic modeling of healthcare suffers, because everyone ignores the reality that the money is not spent by the beneficiary (patient) nor by the provider hospital or healthcare system (they bill for services, but they, as are private insurance, are beneficiaries and intermediaries). The expenditure depends on the actions and documentation from a physician or non-physician provider (PA or nurse practitioner, for example). No one really understands how this happens, and no one really understands what the value is and how value is really derived from the work and other expenditure in providing healthcare. No one is paying attention to what waste really is, although Republicans certainly love to talk about it and can't quantitate it with any data. In a sense, the inverse of waste is value, and that also remains difficult to define and to quantitate.
What I hope for, but will likely never happen, is for the doctors in this country to awaken and react. Docs are the sleeping giant here. Will they start to tell the likes of RFK that he and his bosses have gone too far?
The vaste majority of doctors in Britain work for the NHS. Many consultants run private clinics on the side but it's a usually a supplementary source of income.
Actually, Prince George and his siblings were INDEED born in an NHS hospital: St Mary’s Paddington, which actually happens to be my local hospital. Despite the NHS being a bit of a behemoth (I’m Australian and prefer the Mutual Benefit systems there and in Belgium, which is fairer and more effective than « everyone pays nothing, even if they earn a lot »), I’ve had just brilliant care at St Mary’s over the years… even though I was a low-paid public servant. My care was free. And yes, from Harley Street surgeons, who all put in stacks of time (and care) working for the NHS. There is a reason it is so dear to the heart of the British…