As a retired small town family doctor, I advocate a federal national health program. Indeed, Medicare for All is the idea. But getting there by way of the buy in may be the most practical and possible--and probably the quickest. Getting to the end by the most expeditious means may be the principle.
I am a retired Internist who worked in Academic Medicine, Public Health, and finally Private Practice and there are a lot of tweaks which could be worked into the creation of such a system. First of all the exodus of younger people into the Public Option will drive up further the cost of the Private system. We as a Nation can no longer afford this high-priced system which leaves many with no coverage at all... Medical Bankruptcy is a concept unique to our American System.
"But look at which sector gets even worse ratings: the federal government. That’s deeply unfair to the many dedicated men and women who try to make government work for the people. Yet unjustified as it is, it’s a fact of life."
Also fair to say that this poll was taken in August of 2025, with Trump busy gutting the IGs and JAGs and firing all of the non-sycophants while installing folks like Hegseth, Noem, and Patel.
I would have voted "no confidence" at that time as well.
I would like to recommend The Fifth Risk by Michael Lewis to those who still feel that government agencies are bloated and ineffective; it reads like a thriller novel and clarifies the role and importance of "bureaucracy".
I previously worked in the federal government. I'm not going to pretend that every single one of my colleagues was diligent, hard-working, and competent. HOWEVER, most certainly were! Almost all worked with the best of intentions to serve the American public, ALL of the American public. The federal government has no larger percentage of lazy, incompetent, or bad employees than any private entity I've ever worked for. In fact, a large number of my colleagues were some of the smartest and most diligent professionals I've ever worked with. It is unfair and just wrong to label federal employees as a group, as it would be with any other group, and I find it sad that so many of our fellow citizens can't seem to understand that. Like any large company or institution, tweaks could be made to create more efficiencies and fewer inefficiencies. But at the end of the day, what matters is that, up until the first Trump administration (even more so in the second), it worked exceedingly well. Not perfect. Perfection in the realm of human endeavors is not possible. But exceedingly well considering the size of our country and the scope of its remit. Also, you make an excellent point about the importance of knowing when the poll was conducted. I certainly would have given lower marks during the purges as well. But historically speaking, the citizenry loves to bash the federal government. It's easy to criticize a monolith you don't understand or don't have personal experience inside of for all your woes and troubles. It's just the nature of the beast. I'm appalled at the level of civics education in our country. I feel the problem of the view of the federal government held by many could be improved somewhat with more and more rigorous civics education in our classrooms.
Agreed. I've worked in both public and private sectors. My experience is that public employees are, by and large, a little more diligent and competent than private sector employees.
I worked in state and county government--I was a public service careerist--and it was the same at those levels. Folks hated government until they needed it, and then were glad it was there. A conservative friend lost buildings on his ranch in a wildfire. No! He disapproved of FEMA and would not apply for funds. Then he did, and FEMA came through, and he was able to rebuild.
About healthcare: I'm on Medicare, and had difficulty finding providers before going on an "advantage" plan. No one wanted to deal directly with Medicare and thought their reimbursements were too low. My chiropractor is able to charge me just over $30 when her regular fee is $65. It seems like the entire cost/fee structure would have to change. A "buy-in" option might ease the path, but get ready for the anti-lobby battle of the century!
Did your rancher friend change his mind about government after his FEMA success or did he continue to vote Republican because they are “fiscally responsible and advocate for small government” claims we should all now understand were false?BTW I also have Medicare and a private Supplemental plan, which covers co-pays and deductibles of Medicare approved services. I live in a rural area and have not had any issues finding good care.
He may have. He wasn't like the conservative crowd we have now. He didn't always vote Republican, even. On healthcare, I now live in an urban area. Perhaps the system works better in rural areas--although when I lived out, I drove a long way for care. A "supplemental plan" isn't necessarily a Medicare advantage plan though. I hope you continue to get good care!
Lots of interesting comments! Medicare Advantage plans were introduced to, it seems, inject some of the benefits of private healthcare insurance into the system, expanded coverage options for example. The original idea sort of morphed & expanded, & grew more with each Congress. Now I see coverage options contracting, & co-pays increasing--depending on plan. In everything to do with healthcare, I can't get away from the dollar signs. Costs throughout the entire system just keep increasing without end. It's also worthwhile to mention that this Administration doesn't dare touch Medicare. Medicaid--which helps primarily children in low-income families, & the disabled--was fair game, & the courts have not resolved the issue.
When I worked for one state and with state agencies in another, I found much the same thing. Many worked hard, some were average and a few were there to get a paycheck doing as little as possible. Generalizing about any large group misses the mark at least as often as it hits it.
I feel the problem of the view of the federal government held by many could be improved somewhat with more and more rigorous civics education in our classrooms.
Sad to say, but schools can't even begin to compete with the propaganda spewing forth from every social media site. Plus, if a teacher actually tried to teach students how to analyze the propaganda they face, they would be accused of left-wing communistic bias. All it takes is ONE PARENT to complain to the principal and the teacher is toast.
The federal bureaucracy has always had its own take on things but I used to be able to trust them to operate in good faith relative in that context. Now I have to look very carefully to see whether the GOPs political commissary have twisted an agency almost beyond recognition. This is much like the court system abandoning the presumption of "regularity"when dealing with the executive branch.
I read this excellent book during the first Trump administration. I believe that too many who seem to hold the idea the Federal government is bloated & useless would benefit from reading Lewis's book. If only.
Thanks for bringing up The Fifth Risk, an excellent book and an easy read. I spent some of my career as a civil servant in Ontario, and Michael Lewis gets it in a way many don't. He has also written a second book, which I have not yet read, called Who Is Government, and a third due out in October called Blockers which will look at the DOGE catastrophe.
As a practicing and now retired physician who has delt with both "governmental" and private health plans as a provider and subscriber, my experience is such that I prefer the federal plan despite despising governmental control as it now is. Government is the PITS but there are some sections such as Social Security and Medicare health that have performed very well despite the political efforts.
The overturning of medical treatment by private insurances (ala United Healthcare) has led to many sour grapes and it is time for single payer health care to be offered as a public option.
Abdul El-Sayed advocates for Medicare for all and is against leaving what we have in place but adding a public option. He believes the public option will get loaded up with the least healthy and oldest people which Rs, insurance cos., big pharma, etc. will be able to point to as costly and inefficient. What can be done to ensure that doesn't happen?
I'm convinced Musk DOGE'd extensive parts of the Federal workforce primarily to fire Black and other POC workers. Blacks alone made up roughly 20% of Federal workers, and firing as many of them as possible is probably something neo-Nazi Musk considers one of his highest achievements.
A buy-in would have a much better chance of passing as a public option to be purchased on the exchange, for sure.
As more bought-in by choice, it is likely it would likely become largely "for all" but people like to feel they have options.
A public option would also cause the remining private insurers to behave since people would have a better place to go if they do not.
I think it would also open people's eyes to the fact that "low income" seniors pay a lot more for regular Medicare per month than they would for a regular ACA policy.
Now, of course, all one has to do is go near or over the 400% of poverty subsidy limit at the moment, and this problem is reversed since the GOP axed the fix that Biden had put in place causing premiums to spike and this was worse for those older and over the subsidy limit.
Obviously, if we had enough Dems to add a public option, we could also fix the subsidies once again, as well, and get rid of that income cliff.
On the ACA, I paid about 20 dollars a month and since I had no health issues, I did not have to be concerned about a large deductible and the free check-ups were a blessing. So it was much better for me than Medicare. However, to save money I sometimes chose private pay and paid up-front for some things because if they billed my insurer, and I had not met my deductible, I would get a much larger bill in the mail. Many places had super huge discounts for paying upfront and then no surprise bill either. I was amazed at how cheap X-rays and MRIs and some appointments can be, if one pays upfront. I simply would ask and not even give them my insurance card.
In contrast, Medicare is 203 dollars a month for part B for anyone making under 109,000 a year, so I now pay 10X more and no longer have free visits that contain any real diagnostics or lab work for free. Of course the deductible is far lower but then there are other out of pocket costs, as well, and not as much of a cap. To be honest, I will likely have to drop house insurance so I can afford health insurance and even after doing that actually using it is too expensive.
Thus, if it becomes a public option, they need to combine some of the good from the ACA like more of a sliding payment scale based on a percentage of income like the ACA has and once they did that for the exchange, low income seniors would be jealous and demand it as well. Free Dr visits that actually include diagnostics would also be a plus and out of pocket caps based on income would be a blessing too.
The average SS payout is abt 2,000 a month meaning many live on far less of a payment than that per month if that is the average, so 203 dollars + deductible and out of pocket and gap insurance is simply not remotely doable for most.
I would like to see a buy-in to Medicaid, as well, as a public option on the exchange.
People on Medicaid get no bills in the mail so some on a fixed income would choose that buy-in instead of Medicare even if the monthly buy-in was a bit more because there would be no surprise bills and no bankruptcy worries - none.
What a relief that would be.
You may not be able to go to the Mayo Clinic, but still, having no worries is HUGE.
That is what I would choose, for sure.
I have had private insurance, ACA subsidized when that passed, Medicaid and now Medicare and Medicaid was by far the best - the others are not even close. The objective should be "Medicaid for all" not "Medicare for all." I do not find Medicare very good, at all to be honest.
I am on Medicare, but a Medicaid buy-in would be my first choice. Then no worries, that is if they get rid of estate recovery law, as well.
“ However, to save money I sometimes chose private pay and paid up-front for some things because if they billed my insurer, and I had not met my deductible, I would get a much larger bill in the mail. Many places had super huge discounts for paying upfront and then no surprise bill either. I was amazed at how cheap X-rays and MRIs and some appointments can be, if one pays upfront. I simply would ask and not even give them my insurance card.”
The system is so badly broken it’s insane. How is it even legal to charge a higher price to people with insurance. We’d normally call that fraud.
Every year, providers, hospitals, insurance companies and Medicare negotiate billing price and reimbursement amount for every covered procedure. They all play games to protect their own money. Providers increase their price to increase their reimbursed amounts. Just one example: Congress sometimes tries to "reduce Medicare costs" by paying only a percentage of the agreed reimbursement amounts. Providers (including hospitals) understand this game and its effect on a patient. So they often accept a cash fee that actually covers their cost (with some profit) to avoid the administrative expense and time delay to get paid.
Your $500 MRI might have been billed to an insurance company at $1200, but the negotiated reimbursement rate might have been $500.
I don't know why it's legal, but I ran into the same situation here in New Jersey. My pharmacy gave discounts for seniors that were a much better deal than what I would've had to pay going though my Medicare plan.
A big part of the problem is that (a) there is no health care system (“sector” is more like it) and (b) what’s there works just well enough for just enough people just enough of the time so as to make sweeping reform such as M4A very difficult. Call this broken if you want, but tens of millions of people will have no idea what you are talking about.
I think it is legal to charge out of pocket payers less because they can claim they are saving on processing and admin costs, and it is true. In addition, if an ins company does not pay they would prefer not to also have to bill you on top of that (more cost and work for them).
So, they have a good argument to say that it is not fraudulent.
In fact, they might get more of a payout for creative bill coding if they were fraudsters and prefer to bill insurance, so maybe we might think they are even more legit for offing a discount to make their headaches go away.
They bill the insurance what is allowed and needed because they know a certain percentage will never get paid or will get paid only a fraction of the cost, etc.
However, one can’t pay upfront for Hospital stays as they are too expensive although I did to pay upfront for ER visits. So, insurance is needed, etc.
Well, it will always be more expensive to bill someone after the fact, as well, even of there is no insurance and also an increased risk one may never get paid too. It seems to be a natural part of doing business regardless although insurance seems to perhaps have more hurdles. It is not unusual for business to offer some pay up front, esp with cash, discounts.
Medicaid is partially funded by the individual States. The quality will vary from State to State. Some States call Medicaid by another name; people in those States don't even know what they're getting.
Medicare buy-in sounds good, but ignores the financial death spiral that would ensue. A public buy-in is false hope, for the same reason health care in general needs to be seen as a public good: 80% of people use 20% of health care, 20% of folks use 80%. Insurance corporations understandably don’t like paying for health care, so they’ve become expert in covering the 80%, avoiding/dropping the 20%. A public option Medicare buy-in would end up covering the 20%, meaning it would likely combine high premiums with restricted coverage to survive. Plus a public option leaves the extreme level of bureaucracy currently in place. So, a public option would reinforce the (false) belief that government funded care is bad care — not a pathway to Medicare for All.
I suppose you do have a point. AZ (where I lived at the time) had expanded Medicaid long before the ACA came along even though it is a red state, so they had a very good system in place. The voters there via voter initiatives often do very liberal things but for some odd reason often put a large majority of republicans in the state legislator who would then try to undo what the voters had passed by ballot initiative with a huge majority. Thus, it made little sense. I think there was too many who listened to the likes of Limbaugh and watched FOX, but as often the case when you ask them about what they actually wanted, it was what the Dems were offering so there was a mismatch as is often the case in most red state and purple states. I answered your concern about fraud by answering Ronan above who was concerned about pay up front being fraudulent as well.
So, people should be able to choose a public option that suits their needs, for sure.
Well, there was a lot if good and needed stuff in the ACA, as well so to me, all 3 need to keep the good parts and make a new and improved version of Frankenstein's Monster.
They could. One is means tested (and now fraught with insurmountable paperwork) and the other is not. But, if the hybrid was sliding scale and included categories for those previously covered by Medicare, why not? This is probably the easiest part of it.
The two systems are operated under the same roof on the federal level, CMS, and each state’s health services departments. Merging the separate offices within these systems would require some doing—as in, cooperation amidst fear of purging positions.
It’s my understanding that Medicaid provides broader coverage in terms of services, but that may be state specific.
It wouldn’t surprise me at all if health policy wonks don’t already have at least a scaffold for implementing this already written and ready to elaborate on, depending on how the legislation is written.
In his last NY Times interview this past May, Barney Frank advocated for a somewhat different, but still incremental, approach than Dr. Krugman has discussed in this post. He suggested lowering the age of Medicare eligibility from 65 to 60. "You could do it right away, and it would work, and it would build support for going even further." This is the "thin edge of the wedge" approach. Frank was critical of people on the left who want to immediately create Medicare for All; critical because he did not think it could happen all at once like that. Essentially, it would be too much, too soon. https://www.nytimes.com/2026/05/12/us/barney-frank-congress-democrats-advice.html Whatever you think of Barney Frank, both his and Dr. Krugman's approach would be result in a lot more people getting coverage. A good starting point.
If everyone is required to have one-payer insurance, and a public option. there will be a broader financial base, giving economies of scale to the public system. And less administrative waste.
Medicare Buy-In is the way to go. What would it cost companies and individuals per person? Has anyone done the math on estimated monthly cost per age group? One thing that never gets talked about is how much Americans are locked into their job/employer just for the health insurance. So many Americans would retire before 65 except for the $1500/month monthly premium costs. This is not the case in Europe and other countries with national health insurance. Americans think we are so “free” but most are locked into their jobs due to the lack of a single payer system.
As you said a lot of people in their 50's or early 60's would love to retire (or have to due to ageism or heath issues) or move to a part time. However the ACA marketplace with it's high premiums for people between 50 and 65 and $1 over income subsidy cliffs (ask me how I know) make it difficult. Allowing Medicare buy in at 55 seems like a would make that possible for so many and seems like the smallest political lift. However even that will likely be fiercely opposed by the right and the insurance industry as they know it's a start on the road to Medicare for All. In addition business uses the insurance lock in as another lever to control workers and prevent them from leaving.
I agree. I am a retired school teacher. I am hanging on to my health as best as I can with the support of Medicare. My daughter is a well-qualified teacher but will pay a high premium evidently because of her age & teaching in a private school.
Also worth noting-- US MCR is administered thru PRIVATE INSURANCE companies (MACs) who are paid a % of total cost, so they have the same incentives to increase total costs to increase profits that other private insurance companies have.
Also info about the distribution of costs-https://nihcm.org/publications/the-concentration-of-u-s-health-care-spending
The top 1% of ppl cost 20% of the total; the top 5% are about 50%.
Yet 77 percent of Americans with private health insurance report being satisfied with their coverage.
HOWEVER, subsidizing employee health insurance is becoming an ever more expensive proposition for businesses. Also, only about 60% of those employed have employer sponsored health insurance.
A good start would be if folks understood what a misleading ripoff private insurance Medicare Advantage is...looks good in the beginning, but once you're sick, surprise! You're not covered.
My partner did a lot of research when it was time for him to sign up for Medicare and that is also what he discovered. They make it sound like a great deal but they can really limit your care. They are companies doing what they can to increase their profits, not improve your care.
The problem with straight up Medicare is there’s no out of pocket maximum. 20% of a lot is still a lot to pay. That’s one reason why some go for an Advantage plan.
I had advantage from 65 75. But I used it very little so the company got to keep most of what the federal government paid them to cover me. I have been very fortunate. So was the insurance company!
It seems to depend on the plan. Don't just look for the cheapest. Look at your needs and plans available in your zip code. And don't get a plan assuming you will never need xxx. On Medicare I had DVTs, a hip replacement, a pulmonary embolism event. On my Advantage plan I had two surgeries, a knee replacement, two heart attacks, and tons of drugs. I was never not covered. Though practices do ask me to identify the specific Advantage plan and then seem relieved when I name mine.
Wife and I also have Advantage plans through our employer. I've not a had a problem, but the first thing I did before signing up was make sure that all my doctors and all my prescriptions were covered. The first time I'm denied for anything, I'm gone.
Giving options in the govt plan is a very bad idea.
It increase administration costs, and requires different fees for the different options.
There is always the option of private plans (which will cost more), or private supplementary insurance.
This will protect the govt plan from accusations of unfairly priced differences.
Note that states could and probably will participate as well. That means there will likely differences from state to state, both in potential fees and benefits.
But the federal govt should set minimum conditions.
States that don't want to participate will likely feel political pressure from their residents.
How it works (and always has) in Canada is the federal govt and provinces negociate the minimum requirements each year. Gradually this minimum is increased.
The federal govt uses its' financing for negociation, since health is in the provincial jurisdiction, like it is in state jurisdiction in the US.
The provinces are free to a charge fee (or not) for their contribution. The conditions have always included reduced or no fees for lower income users. Most provinces now charge no fees for their residents, with a few exceptions.
Employers which offer health insurance for their employees generally use the public plan, with supplements from private insurers. To the employee, it is just an employer plan.
Gov't plan can be the gov't plan. It needs no option except maybe to retain the A, B separation. People are used to that. But a private plan option that has mandated minimums, but allows for additional coverages as seen in some employer plans (e.g., Lasik, Botox, gym) would help keep the gov't plan honest. The gov't plan would then not be blamed for every imperfection. Why the states should be involved tilts to Medicaid. Medicaid is a super opportunity for fraud as evidenced by billers getting extremely wealthy off its payment practices. States, especially, the poorly run and poorer states, when up to 90% of the billed cost goes into the state economy from Washington often seem to welcome the fraudsters at least by not funding watchhdogs. When a doctor connected to a funeral parlor is billing $$millions$$, sometimes triple digit patients/day, you'd uh thunk the practice would not continue uninvestigated multiple years. And you can always buy a pardon if it's just Federal Law.
But the pay for services (procedure maximums) and paperwork requirements for Medicaid and Medicare seems to be offputting for some providers. When I lived in NY one complaint from a practice my wife worked at was the frequent appointment no shows for its Medicaid patients. They had no skin in the game. Some did not bother to even pick up a phone to cancel. Others had transport problems. Why there is not service for practices to handle billing paperwork is telling. The burdens must be unreal.
I have MA thru a smaller, regional non-profit and have zero complaints. Great customer service and never had an issue with a claim (and I've had many in the past 12 months). MA gets bad press but I think it's from the practices of the large national groups denying claims.
I have MA with Aetna. The only complaints I have had is that they denied my second Shingrix shot. They also want to send one of their health specialists out to my home, instead of having me see my doctor for a real exam. I ignore those calls.
I have Medicare Advantage with Kaiser of Northern CA. Super happy with them. They are big enough that as an HMO they do everything in house. Never, ever do their in house doctors think/care about costs. One thing I am concerned about is that they do pile up diagnostic code presumably so they can get higher per-capita payments from Medicare. I've read that this is rampant in the Medicare Advantage industry, and I'm not happy about it.
I think the biggest scam is the in-house visit to look for upcoding excuses. Leave it to the clinicians you see.
That said, the upcoding is by the numbers. We need some kind of control. I have two conditions of by the numbers heart failure (and some other medical history conditions that require vigilance), so upcoded on 3 scores (after 2 MIs), but no restrictions on my activities, except for things like sky diving and contact sports. I do miss the rugby, but the skydiving . . . . . .
Members of Congress were already hearing that from constituents in 2001--four years after it was created. In rural areas, people had no providers available. It's ideology-driven and makes no sense in health care.
Many seniors (including me) opt in to Medicare Advantage for one reason: Regular Medicare has no maximum out-of-pocket limit. If you get some really major medical problem that can break you. My Medicare Advantage (the nonprofit Health First in central Florida) has a $3,400 out-of-pocket maximum, and I have to say, very good service too. But if regular Medicare would institute a maximum for out-of-pocket expenses, I dare say that there would likely be a rush to regular Medicare and an abandonment of Medicare Advantage by many, many people. I suspect that the insurance companies likely have had a hand (i.e. lobbying dollars) in making sure that Medicare has no OOP maximum. That one thing could make a huge difference. BTW, you may have noticed that a few years back Congress passed a bill to limit OOP costs for drugs to $2,000/year. It was going to take a few years before it kicked in. Now that it's supposed to be in effect, the Trump administration is indicating that they want to repeal it. Yeah, what a surprise, huh?
My husband and I have always had Medicare advantage. I’ve never had any problems with it. When my husband was very ill and needed surgery, I was very glad to have Medicare advantage. I can’t say enough good things about it.
BTAM, I have read many comments on several different occasions similar to yours. I am on an Aetna plan in Oregon and have not had any significant problems except we have to choose providers "in network" or be charged a higher copay. In addition, Aetna covers up to 80% of some of my dental procedures, whereas Medicare never covered any dental. And finally, we no longer have to buy a private supplemental as was necessary with our Medicare. The premiums for supplementals seem to be pegged to age, and I have a hunch that it would now cost my wife and I (both mid 80s) around $300 a month each--over $7k a year.
I would rather not be participating in a program that is a ripoff or semi fraudulent, and am curious to learn more about your experience or knowledge of scamming MA plans. Would you be willing to share the gory details that you've experienced?
I too had MA through a major national provider, but have now switched to Medicare plus Supplemental (only because a life change afforded me a one-time-only chance to leave MA w/out penalty) and am much more satisfied. But let me list the ways I saw that MA can scam the system: 1) you’re pressured into recurring home health evaluations by a nurse or RNP that tell you nothing of added value beyond what your regular medical team provides and that MA providers then bill back as specialized home care, BTW, these must be so lucrative to providers that I’m constantly getting live sales calls to schedule these visits even though they cancelled my MA policy years ago; 2) you’re nudged into using their proprietary RX mail order supplier through teaser rates and easier access thereby giving them bulk purchasing advantages deliberately not passed through to you and they put local pharmacies out of business (the Amazon effect); 3) their summary of expenses divided up (MA/regular Medicare/yours) is totally black box and virtually unassailable leaving you to accept and pay their calculations on deductibles, copays and added charges that Medicare will not cover; your eventual OOP for any given transaction is also untethered in that the same visit to the same clinic in the same calendar year may have a different net charge to you based on the algorithm summing up your expenses to date and history of use so as to maximize their net year off take from you and regular Medicare. I could continue but if you’re happy with it, keep on keeping on.
I have never personally had MA; I have regular Medicare with a supplement. I have had cancer (recently celebrated 5.5 years cancer free) and a cardiac surprise resulting in 3 stents due to blockage. All I paid was co-pays for the tests and a co-pay for the ambulance. I have not had any denials and was able to choose Mass General in Boston for my cancer treatment.
Friends with MA have mentioned routine denials, required referrals, higher co-pays, and the hoops they’ve jumped through to get routine coverage and (in one case) to get off MA and onto regular Medicare.
Under Medicare, I do not have dental coverage, which truly is a bummer.
I will be the first to admit I am pleasantly surprised by the folks here supporting MA...I do not have any friends on MA who are long-term happy with their decision.
That Mick Jagger principle is doing a lot of work here.
Medicare for All may be the cleaner moral architecture, but a Medicare Buy-In may be the door people are actually willing to walk through.
The key distinction here is tactics, not values. If the goal is universal care, the path has to survive the insurance lobby, public distrust of “government,” and ordinary fear of losing what people already have.
More Medicare, less private extraction, and a transition people can recognize before they are asked to trust it. Get me?
I like the idea, but that will mean that it probably won't be properly funded the way that public transportation and public health are in Germany, because everyone uses it. Medicare does not cover dental, which means people can still die due to tooth infections etc... and be ill because of poor dental care. That needs to be fixed. My mom is on US medicare, and I am when I am there, because I am covered by Part A. Otherwise, I get my medical care in Germany now. We are paying a fee based on income up to a ceiling and our daughter will be covered too, as long as she is in university or in an internship related to her studies.
I still think an option is better than what we have now and a door in. It would be great for Paul to share this with Abdul El-Sayed, and other candidates who talk about Medicare for all as a means for them to tailor the message with the goal is medicare for all, and the plan is to start with opt in.
Dental, vision, and hearing absolutely need to be covered. Who's willing to go without coverage for their teeth, eyes, or ears? An ounce of prevention.
This is a fundamental flaw with health insurance regardless of system or provider. Health insurance should unquestionably cover the entire body. It is all linked. Dental issues can lead to other bodily issues. Bodily issues can lead to dental and vision issues. They are not independent systems. It should all be included under one health insurance plan for that reason alone. Additionally, surely it would also improve continuity of care.
Absolutely. How do you think my mental health was when I was in crippling pain from a molar that needed a root canal? I was lying on the couch whimpering, unable to do virtually anything. Of course that affected everything else.
I always "joke" that insurance will not cover vision care, but they will pay if you don't see the car coming and you end up in the ICU for months. Penny-wise and pound-foolish.
Exactly. The ACA forced more coverage and focus on preventive care, but still not enough. Moreover, as others have noted, it’s all inter-related. I’m diabetic. When I was diagnosed, they told me diabetes often affects 3 body parts: feet, teeth, and eyes. Sometimes issues with those are the first sign you may be diabetic. I’m supposed to get annual foot and eye exams. So why the !@#$% are my feet covered but not my teeth or eyes?
My Medicare Advantage plan covers vision care. Dental would be extra. When I was still working, my private insurance policy also covered vision. Both plans had co-pay requirements (my current co-pay is $40 per visit and something over $100 for an operation).
Given that by definition, insurance premiums exceed the cost of care, plenty of people prefer to pay for things like dental and vision care directly, knowing they are likely to save money in the long run, so long as they can afford the short term volatility. Same with way physical damage to your own car, or high deductible options for homeowners.
Decades ago, my then husband tore his Achilles tendon and required surgery. We received a bill that for $10k for the surgery. Husband had become buddies with the orthopedic surgeon and called him in a panic. Surgeon literally laughed and told him, "Oh, that's if you didn't have insurance. Since you do, the insurance bills us and will end up paying $700 for the surgery. You're good!" (And I didn't forget an extra zero on the "$700.")
I agree that is one of the more damnable aspects of our current, Rube Goldberg healthcare system. It’s why people only chose to go uninsured in niche areas that are less mysterious.
Today, I wrote instead about my Bugaboos with German Universities.
Not nearly as much as with US health care. I wrote about that a while ago when first finding out about my mom being thrown out of original medicare and put on an [dis]Advantage plan that did not cover her primary care.
You mean her policy didn’t provide coverage for the primary care provider she was using so she had to switch to another, right? Medicare always covers primary care but if your plan has a “preferred provider” list you have to choose from. I am confused about who forced her to change? Individuals on Medicare either enroll in traditional Medicare or opt to choose from the various Medicare Advantage plans. The only instance I can think of that someone else makes that choice for you is if your employer makes that decision for you if choose to get your coverge through them. I know several people on Medicare Advantage who still get employer coverage as part of their retirement benefits.
No. Some guy who got paid a fee, but did not get permission from my mom or me, and the Advantage plan he switched her to without any permission did not cover her primary care and it took me over 4 months to get her different coverage after I found out about this. I have the guys name, but have not yet called him to ask for proof that he got my mom's permission and Medicare has nothing in writing. My mom has dementia, so she could not have done this on her own. I am sure this is happening to a lot of people. It is easier for some stranger who is paid a fee to switch someone's medicare plans, with no proof whatsoever that she agreed to it other than his say so, than it is for me, the person who has legal rights to make decisions for her.
That’s us. Every sick day we didn’t take while employed rolled into a post-retirement health care fund. But the catch is that only the employer’s preferred provider is available, which turned out to be medicare advantage plan with united health. It is generally decent coverage but quite limited for eyes, ears, teeth which are turning into major expenses for us. Still, it feels like most stuff (including my husband’s cancer care and my own rheumatoid arthritis) get well covered.
Argh. Will read. I'm in the Netherlands myself, planning to move back this fall. Health care is cheaper here but has many other problems. I need a permanent crown on a tooth the dentist estimates at €750. My good insurance only pays €500. I don't really have the other €250.
Oh, I paid $2400 for a crown in 2003 when I had strong health insurance as a federal employee. Insurance reimbursed...$40. I had other plans for that money, like a bicycle. But I'm not allowed to work in NL. If you don't have the money, you just don't have it. They'll partially subsidize health premiums, but not fully, and not other costs. I'm holding out until I can get employer-sponsored insurance in the US again.
Jon, Germany has out of pocket dental expenses too. However, I am finding the costs for my mom's out of pocket dental expenses right now to be much more in the US, since dental is also not covered in Medicare. We have an office in Chicago where they have their own in-house insurance plan, but that is more for regular care and costs around $600 a year which includes a check up and cleaning and some other things. However, my mom cannot use it, because she has problems that need more help. My aunt, who is also in Chicago said that she has always paid dental out of pocket until she joined a certain Advantage Plan that covers it.
The problems people complain about here in Germany with health care, like waiting for appointments is no different than I had in my health care in Chicago, at the University of Chicago Medical Center where our doctors were.
Agree... I live in upstate New York, and we have a terrible time getting timely appointments. The issue isn't about insurance, but provider shortages. I wonder if that's an issue where you are in Germany?
During their 14 years in power the conservative Tories underfunded the NHS. Today it is in such bad shape it has forced many people to turn to private health care — which is exactly what the Tories want.Just as Republicans her privatization/the “free market” is their magic cure-all. But if the Labour Government doesn’t fix the NHS quickly they will be blamed even though they are faced with serious budget problems caused by Brexit. The UK media has memory-holed the colossal Brexit mistake pushed by conservatives like Boris Johnson and far right leaders like Nigel Farage. Even the BBC, cowed by years of conservative threats to their funding, doesn’t bring it up when interviewing Farage:
“Farage collapsed the economy with Brexit, and faced no consequences’ – Stephen Flynn:
With the BBC facing criticism about the amount of airtime they are giving Nigel Farage, some awkward questions have started to emerge.”
Theodora30, Glad that BBC is getting some push back about giving Nigel Farage air time. It is basically a means of spreading disinformation unless they refute what he is saying. German media does not do that with US disinformation I have noticed and I write my complaints.
I have Medicare Advantage with dental and almost all procedures I get are denied. Don’t be fooled! They also will not cover regular medical procedures if you are outside your coverage area like when visiting out of state or going on vacation. Try harder to get what you need and don’t sabotage it because of fringe issues. Common goals are needed to get it passed! Worry of about fringe additions after you get the basic program.
Yes. I understand. That is what we are doing. Still, it took me months to straighten everything out. I have notes because I had to make so many phone calls. I could tell within the first minute if the medicare rep was going to be helpful or difficult, but I had to talk to whomever I got.
So many seniors are so heavily in debt, thousands of dollars, because of dental bills. Evert time we save for a vacation, another dental problem arises, and we must use those savings to pay the dental bills
I am sure. It is one reason I left the US. I did not want to deal with the constant threats to medicare from the Republicans, and the idea that health care is a privilege not a human right. People told me I could not get into the German public health care system after retirement, but I did. I am a citizen, what are they going to do? I have asthma a pre existing condition which is better controlled when I live in a place with cleaner air. Yay! Still, private insurance does not like to insure people who have pre existing so I knew we were going to go for public, which is what everyone I know uses. It covers 90% of the population.
Yes, absolutely! I keep wondering what idiot decided that teeth and eyes aren't part of the human body. I have a supplemental dental plan for Medicare. It paid $479 on a $4000 root canal. Yahoo.
I think that your argument misses the more important point: healthcare is costly, it comes around when we least expect it, and both the diagnosis and the price tag of the treatment can be overwhelming.
As a doctor (retired now), I’d advise people to think more about getting through the acute situation (the diagnosis/ the accident), and to put your concerns about ‘choice’ of physician/ whether you get a private bedroom or not, to the back of your priorities.
The costs in the US are exceptionally high, and US Americans do not get better care.
The costs are rising and will rise further.
Paul’s arguments are partly about what system might keep healthcare costs more sustainable, and partly about what degree of mutualisation of risk Americans are broadly willing to accept.
One reason the cost is so high is the tort system. Lawyers and their lobbyists will tell you that if you get affected by a medical mistake, you deserve your day in court. I don't want a day in court - I want to be fixed up. That's also the reason hospitals are run by Byzantine labyrinths of detailed procedures for every "what if?"
We have to think about both. It would be nice if it were simpler. I have my mother covered the best I can, and unfortunately, insurances we paid into will not follow her out of the country.
I am not sure what state you are in but there are Medicare Advantage plans, some free many cost with buy ins for dental, eyes, etc. You have to read all the small print. The open enrollment periods are in the fall
It’s worth looking into. Still not the greatest, this year I had an eye check up included but the glasses were only covered nominally. That’s why it is important to read the small print and listen to Paul Krugman’s Musical Coda today. Don't call the telephone number from the companies which advertise in-between local news, if you have a Senior Center that is close to you try asking if they have a representative there who can explain the plans, so you don't get involved with anything untoward. Ask questions get information before you share any personal information.... A lot of caveats, but you want to gather information before you give personal information. Some states produce a list of Medicare advantage plans which are available in your area which you can view online .That's my take on how to search for the correct product best regards
We have the same kind of coverage for eye exams. We just take the prescription to Costco to get glasses instead of getting it through the ophthalmologist’s office.
I used to do the same, but the local Costco provider puts that "blue-blocker" tint to all their lenses now. Since my major hobby is taking and processing photographs, I only deal with optical outfits that provide me with clear glass lenses.
I know a lot of people who have switched to Medicare Advantage plans and I am covered by MA through my spouse’s retirement benefits. No one I know has switched back to traditional Medicare, which you can do during the yearly enrollment period. I have also read horror stories but no one I know has had problems. I do wonder if it depends on which company you use or what state you live in. Apparently states play a role in Medicare Advantage oversight so I wonder if that is also a factor in how reliable coverage is.
If you don’t choose a Medicare Advantage plan you need to pay extra for Medicare Part D to get coverage for prescription drugs. Many people also buy private Medigap plans to cover deductibles such as for hospital care. Medicare Advantage plans combine these kinds of coverage into one plan but you have to look carefully at that the different plans offer.
It’s very confusing.States offer free, non-biased advice through their State Health Insurance Assistance Programs (SHIPS).
The National Council on Aging offers advice on how to talk to about choosing a plan.
Wouldn't the affirmative 'choice' component, where you have to decide & choose it, help reduce any conspiratorial blowback from the far right as well?
You know, you move 350 million people from one 'folder' to another 'folder' and you're bound to cause enough problems to create conspiracies. You let people 'choose' and you now have personal testimonial as to how good of a choice it was.
Central Limit Theorem question, because let's face it, Insurance risk is a CLT question: would the gradual move allow a 'Medicare for All' plan to adjust gradually as they work to find what the CLT says real 'risk' is for each demographic group? Or would the people who 'choose' have characteristics/patterns that throw the average 'off'?
The fact that Walmart etc minimize work hours so as not to provide health benefits to staff is part of the problem. Employers should be taxed per work hour for every employee who they do not provide coverage. Those taxes should be used to subsidize coverage for workers at those companies. The freeloading by major corporations with respect to insurance and other externalities is despicable.
Please do an economic analysis of lowering the eligibility age for Medicare, incrementally. Since Medicare is the most popular government program, expanding its current format to more people would also be popular. Doing so would reduce or eliminate the fear factor and likely generate a political groundswell for Medicare for all. Seems far simpler than a buy-in option, which would create a new tier to the health care system rather than just expanding what already works.
They need to do both - living wage and insurance. They can do both. They choose not in order to funnel the money up the ladder to execs, legal teams, consultants, shareholders, and the like.
I’m in favor of fining every company double the amount the government spends to support their employees. That would increase pay and benefits quickly enough.
"But look at which sector gets even worse ratings: the federal government. That’s deeply unfair to the many dedicated men and women who try to make government work for the people. Yet unjustified as it is, it’s a fact of life."
We've had half a century of Republicans telling Americans to hate their own government. Indeed, starting with Ronald Reagan, every Republican president has made it a point to tell voters how much he hated the government of the United States. And once in office, every Republican president has done everything he could (and in the case of Trump, MUCH more than he's allowed) to disparage, damage, or destroy the government of the United States.
So is it any wonder that people hate their own government? The implications for implementing Medicare for All are obvious. But the implications for the continued existence of the country should also be obvious.
People who say government is the problem should not be allowed to hold government positions. If you or I told a prospective private employer in a job interview, "Your organization is the problem," I doubt we would be hired.
There’s a guy in our neighborhood that puts the same sign up every election. “Two term limits for politicians: 1 in office then 1 in jail.” It confounds me. If that is how you feel, then work to make it better, don’t disparage it and turn it into a joke. It is so cynical and just perpetuates the legitimate problems that do exist. But it will come as no surprise when I also inform that it is always next to a bunch of signs for right wing, MAGA type candidates. So, the irony is lost on no one that he is voting for the very criminals he seems to be complaining about.
There is a failure of imagination at work here. People who hate the government or put up cute little bumper stickers like 'taxation is theft' have no idea what would happen to them if our government disappeared. Basically, all their rights would disappear with it. People need to watch The Postman, a post-apocalypse movie that shows pretty clearly what life is like after the government collapses. I watched it last back in summer 2024, and I actually felt a wave of fear thinking that Trump could win the election. Well, here we are... though we're not at 'the Postman' levels yet, thank God.
Yes, and complete ignorance about history and the evolution of how we got to more government services providing for the greater, common good. A simple example is the fire department. Once upon a time, if you didn’t pay for private fire insurance, your house might burn down…unless you could rally enough neighbors to try and help put it out…which brings us full circle to why it’s not about the individual but the group. We need one another to have a successful society and government is the framework for making it work. That doesn’t mean it’s perfect or that change won’t need to happen as life evolves, but we can’t have successful society, be successful individuals, without it.
The fire department situation was the case when I was a boy in Knox County, Tennessee. I recall a house catching fire a mile or two away from ours. They hadn't paid for fire protection. The fire department came and watched it burn, while making sure it didn't spread to the neighbor's property.
The problem is the clueless people who claim they want good government and then vote for a party that has pledged to drown government in a bathtub. Then they appoint incompetents and corporate insiders to run government into the ground. When they ultimately fail, these same clowns claim that "government is the problem".
The question of hating the government should be two different questions. One about the government officials you may have had direct contact with and the other about those who wield power broadly. I’m fine with the letter carrier and the lady at the social security office. The government officials that make the news are another story.
Very good comment! The word “bureaucracy” is a label purposely misapplied by both Rs and Ds to castigate government employees…local, state, federal…as lazy, inefficient, uncaring and incompetent.
It’s a politically-based label and like all such labels is used to attract votes for “Change”…AND IT’S NONSENSE!
Every organization, corporation and government dept is a bureaucracy!
Every. Single. One.
They all have the same pyramidal structure. And when any organization fails, those nearest the top POINT DOWNWARD and blame those below…the bureaucracy (or ‘workers’) who are there everyday doing their best to succeed DESPITE the failures and incompetency and, too often now, the outright criminal actions of their leadership.
We pay $1800 a month for medical insurance that covers nothing and the insurance co will - and has - denied doctor recommended procedures. He'll yeah, Im in for Medicare buy in.
I often think about this in passing, never really crunching the numbers. I think because of our extremely convoluted and confusing system, Americans have an odd view and difficulty even really understanding our own health insurance. We have monthly premiums but it is still not always, usually never, clear what we will actually pay because it can vary so wildly depending on the plan as well as the issue. Is it routine, emergency, chronic? In or out of network? What is your copay and deductible, individual and family? Does your plan cover blood work, imaging, transportation? That is just the tip of the ice berg.
Good point, "We pay $1800 a month for medical insurance that covers nothing."
So many focus on WHO pays and miss that the total cost for providing medical care in the US is way too high and growing at an unsustainable pace...
Am I correct in inferring from this that reforming the market for medical care (limiting monopoly, transparent pricing, etc.) would be a harder sell than expanding Medicare?
My wife and I are highly satisfied Medicare enrollees. Because our retirement income is higher than average our premiums are subject to income related surcharges, resulting in a fairly stiff total yearly bill. Making people with higher incomes pay more is a concept that should be carried over into a Medicare Buy-in.
"Woke," when aligned with empathy and compassion, is defined by many as being aware of social, racial, and political injustices, aimed at fostering a more caring, inclusive, and equitable world. It emphasizes understanding the human behind every story, listening deeply, and actively working to alleviate suffering.
• Awareness & Action: Originally rooted in awareness of racial injustice, "woke" has evolved to represent a broader consciousness of marginalized groups and systemic inequalities.
• Empathy as Strength: Proponents argue that empathy—feeling the pain of others—is not weakness, but rather a strength that guides a desire for a fairer society.
• Compassion in Action: While empathy is feeling the suffering, compassion is the desire to relieve it, and kindness is the action taken to do so. Supporters see this mindset as leading with love and humanity.
Ultimately, being "woke" is a conscious, ongoing effort to recognize one's own biases and to care for the well-being of all people, regardless of their background.
Now, who could possibly oppose such a beneficent course of action? Possibly only those who are filled with anger, hatred, jealousy, envy, paranoia and ignorance.
Say it loud,
I’m woke
And I’m proud!
THEY should try it.
Please: Resist. Stop cooperating. Stop spending. Stop the fascist takeover.
Thank you for restacking, and sharing, to help Spread the Word!
I have a book called WOKE, which I used to teach the meaning of the word to my fourth and fifth grade students. It is basically teaching the idea that WOKE means you are alert to what is going on around you, something that non White people, and women always have to be. Although, I am currently living in a country that was at place 15 on the Global Peace Index, then dropped to 20 these past two years, and now, in part thanks to the AfD, has slipped down recently to place 28 on the GPI.
How is being woke all that different from being a good Christian? In both cases, it’s more of an aspiration than an actual state of grace, with most of its acolytes falling short.
"We grew up on Scripture and the story of the rich man and the beggar Lazarus was powerful. The beggar lay at the rich man’s gate, hungry, covered with sores, and when he died, angels bore him to heaven where he sat at Abraham’s side, and when the rich man died, he went to Hades and sat in flames. He looked up and begged Abraham to send Lazarus down to touch him and ease his pain and Abraham told him to go to hell. You don’t need a Bible scholar to figure this story out.
A wealthy country with vast farmlands allowing its own children to live on the edge of malnutrition is, if I read Scripture carefully, a damnable sin. Malnutrition of babies can lead to lifelong disability. Think on it." - Garrison Keillor
Agreed, but there's no possibility of progress unless we win elections. Forget the irredeemable FOX-GOP cult; it's any voters in the middle, for whatever reason, who have a "better nature" that can be appealed to, who'll make the difference.
And I think that for those people just the language of wokeness is a knee jerk turnoff. No one, including decent people who haven't had the time or opportunity to reflect on their beliefs, likes to be condescended to or be given the impression that the life they've been living has been a lie.
So for me, 'it's the language, stupid." Best exemplified by the term "Latinx." Empathetic people are supposed to be able to "stand in other people's shoes," yet Latinx advocates seemed to have zero concern for how (especially ) Latin men would react to the suggestion that the very language of the culture they come from and may still speak makes them sexists who need to be reeducated?
Using simple and direct language appealing to one's better self is the way to win, and winning is the only way to make progress possible.
Your words speak both to the heart and mind. If “woke” is as you have it defined, then yes, what reasonable person would not be in agreement with you? However and sadly the term has been so badly tainted that I would use the word “awakened”. As in I have been awakened to my interconnectedness with the whole of humanity. I have been awakened to a desire to cooperate and contribute to the betterment of society as a whole. I have been awakened to the sufferings of others. The challenge now is how to awaken those who would rather remain in the dark. Who would rather cause harm. Or those who are too fearful to speak out. Still, your words resonate and my sincerest desire is that, like seeds of hope are spread far and wide. Thank you for your contribution.
Oh I know of it’s origin. And the original meaning is to stay awake as the good book says. Stay awake for you know not the hour when…it was as a cautionary note to the community but it’s become so toxic that like many other labels I prefer to speak plainly so as to reach out to all who can hear. Labels are just like taglines and headlines. Distractions that take you away from the meat of the story. Thanks for your reply.
Paul - yes to universal coverage, but Medicare is NOT the right option - Medicaid is.
Here’s why Medicaid for All makes much more sense.
TL:DR - Net is Medicare for all sounds great until you think thru the details
- Medicare coverage is convoluted and confusing (e.g. X days in rehab allowed then no coverage for nursing home care),
- has little experience with families, moms and babies,
- requires/involves supplemental coverage from commercial payers
- Medicaid includes some state funding which makes it much more politically palatable
Medicaid for All will spread the cost of universal coverage across states, reducing federal financing requirements.
Medicaid is a state AND federal program; States provide a lot of the funding for Medicaid; on average the Feds contribute 63% and states 37%. This is critical, as Congress will want to spread the cost of a Single Payer solution and there’s no better way to do this than require states to pony up big dollars [State contributions vary based on a state’s average personal income relative to the national average; states with lower average personal incomes get more federal dollars.]
Medicaid is already built to cover everyone. Medicad covers people of all ages, Medicare is very much elder-care focused.
Adapting Medicare to handle everyone from newborns to elderly, maternity care to pediatrics will be difficult, time-consuming, and expensive. Medicaid does all this and more - today.
Generally, Medicaid is less expensive than other “systems”.
This is due to much lower provider payment and significantly lower administrative costs. Yes, this means providers are going to be paid less - in some cases a LOT less.
- that includes device manufacturers, home health care agencies, drug manufacturers, facilities, physicians…
Medicaid member satisfaction is pretty good; access to care is not much of an issue.
Medicaid-based Exchange programs are much more successful in the Exchanges than commercially-based plans.
The Centenes et al [Medicaid-based plans] understand the demographics of the uninsured, have lower medical costs, and already have provider networks, customer relations operations, workflows and processes set up and operational. At the end of the day, lower cost wins - and their costs are lower.
Medicaid is a simple, fully-integrated healthplan.
Medicare’s alphabet-soup of Parts A B C and D - plus Medicare Supplement - is confusing and convoluted, with different payers often covering the same individual. This increases administrative costs, member hassles, and decreases quality of care (co-ordinating pharmacy and medical care between different payers is problematic at best).
Managed Medicaid plans are working.
These plans currently exist in most states, and many have been able to deliver excellent care at lower costs through innovation and very tight focus on outcomes. One example is using paramedics to deliver care. [disclosure - I sat on the board of Commonwealth Care Alliance, a Massachusetts healthplan that serves dual-eligible members]
I don’t disagree with you on the merits. But the messaging will never work. Medicaid is irrevocably associated with being poor and low-income, and no one wants to be considered to be so needy as to qualify for Medicaid. I expect a lot of middle-income people who could benefit from it would be ashamed to join. We are a very class-based society.
Not only that, but the individual States pay part of the costs. That ranges from 21.9% in New Mexico to 43.8% in Massachusetts. You will never get this through as long as the States have to foot part of the bill.
My concern with that approach is that asking citizens in their 20s and 30s today to pay noticeably higher FICA for 10 or 20 more years before they are eligible to receive the insurance is likely to face considerably more resistance than letting them buy-in right away.
I suspect that in the 1950s and possibly the early 1960s, when middle class economics were better, it would have stood a better chance.
Also, this approach essentially ignores the problem of a lack of preventive care amongst younger people, which can help avoid many far-costlier conditions as they age. Getting younger people covered ASAP should be a high priority for any reform option.
They should do it in a way that fica only goes up if your job healthcare premiums go down to compensate. This actually would be easy to do if we moved the young us to single payer as well.
Wouldn't Medicare for All also make US companies more competitive, because they wouldn't have to pay insurance premiums? If Medicare were mostly funded by taxes on corporations, couldn't those taxes be less than what they currently pay in premiums? And wouldn't the economy as a whole be more productive without a whole industry (i.e. health insurance) devoted to denying people healthcare? And would another incrementalist option be to decrease the eligibility age of Medicare by one year every year or so? Or, as a cheaper option, add in 20-year-olds each year, so that all will be covered in 45 years without upsetting people who are happy with their current insurance? These are not rhetorical questions; I would like PK to address them.
The last sentence of Professor Krugman’s post is the key. Elect people who are committed to providing Americans the healthcare they deserve. Hopefully voters in the South, Upper Midwest and places like Ohio are paying attention. I’m not holding my breath.
Cook Political Report just shifted 2 US House races in Ohio from Safe to Likely Republican yesterday, explaining that both Sherrod Brown (D) and Amy Acton (D) are likely to win their races.
the statewide and congressional races? I think the point is that the overall atmosphere in the state is shifting toward Democrats, so if the ones at the top of the ticket are winning, there's a good chance they'll pull some lower-ranking Dems across the finish line with them. I'm not connected to CPR, but they're longtime, credible political analysts.
I think "safe" is considered stronger than "likely". So the districts were formerly "safe" for Republicans, but now that expectation has been lowered to just "likely"; i.e., Republicans will probably still win, but the Democrats are going to give them a run for their money.
Among political analysts, those are standard categories. A given race is classified as Safe, Likely, or Lean for either party, or a pure tossup. Admittedly, it's a bit of a niche most people aren't familiar with. I looked on their website, but the explanation is behind a paywall. I tried to screenshot the email but couldn't paste it here. There are so few competitive House races anymore that the vast majority of them are Safe Democrat or Safe Republican.
This looks very much like Buttigieg’s “Medicare For All Who Want It” proposal, which I fully endorsed at the time.
The point I’d like to see addressed is as follows: today I, and tens of millions more, pay for Medicare but don’t use it. I use instead, and pay for, private insurance. The net result is that I pay into two programs but use only one. Assuming both programs are actuarily sound, my private insurance collections and benefit payments per covered beneficiary are the same, but Medicare collects a much smaller premium per payer than the benefits it pays to patients. Moving people into Medicare Opt In would mean having more covered individuals with essentially the same revenue, and that won’t work. You’ll need to increase the premiums everyone has to pay.
Yes, the new beneficiaries would offset the Medicare tax increase with the savings of no longer carrying private insurance, but for those who want to keep their current insurance, it would be just a big tax increase.
You’ll need to make the case that Medicare is as good as your current insurance, and hence people can and should safely drop it. It’s a case that can be made, but it has to be made strongly. Otherwise the resistance to drop your current insurance will doom the effort.
Also, someone should run some preliminary numbers to see how much Medicare would increase per payer to cover the new beneficiaries. And because legacy beneficiaries are old and retired, and can’t absorb large premium increases, young beneficiaries would likely pay higher premiums that they would in a private scheme.
I still support Medicare Opt In, I support it very strongly, but a lot of details should be fleshed out
What this ignores is that Medicare and Medicaid both have inflated costs by virtue of the population groups they serve. Who knew that poor people and seniors had more expensive health care needs?? And poor people had even less ability to pay them? Well, everyone. As Medicare picked off younger, healthier patients to insure, the per capita costs would fall. The overwhelming share of health care spending comes in the last few years of life.
You should check out El-Sayed's book, which gives a lot of the details of how a Medicare for All system could work. Also his podcast, and others that he's been guests on, have episodes that go into pretty heavy detail about how Medicare for All could work.
As for Buttigieg... there's a big problem I have with his plan, and others. An enormous chunk of the 2020 democratic presidential primary field (including Buttigieg) supported a public option over Medicare for All. As they dropped out, they coalesced around Biden, who also supported a public option and became its sort of standard-bearer. Biden, of course, won the election and then got into office, and then... proceeded to literally not mention his public option plan a single time his entire presidency. And I mean literally literally, not figuratively literally. During COVID, somehow he managed to completely ditch the issue, despite health coverage being at the top of many Americans' minds.
So there's a trust problem, right? How can I, as someone who really likes the idea of Medicare for All, but was willing to jump onto the public option train thinking "well, it's still much better than what we have", still believe that it's a serious proposal and not just a talking point used to crush progress towards Medicare for All? I don't trust that the bulk of more moderate candidates that pushed for a public option actually want a public option. I think they're more interested in keeping things as they are and making sure health industry checks keep flowing into the democratic party.
The democratic party moderates had their public option shot, they stymied Medicare for All for 4+ years for seemingly no reason at all, made absolutely no progress towards a public option (didn't even talk about it...), all while claiming that the public option was the better choice because it's the one that could actually get done. Meanwhile, progressives have continued pushing for Medicare for All in that time and now it arguably has much more support than it did. So tell me, which plan has supporters that actually believe in it and aren't just using it to get past democratic primaries? To me, the answer is clearly Medicare for All, and the trust of a public option is destroyed.
You have to appreciate that there is a world of difference between "dedicating full effort towards something" and "not even mentioning something once". There's a lot of room between those two. Not mentioning it a single time is on the extreme end, akin to apathy.
One of the greatest strengths and roles of the presidency is to be a policy advocate to build support for what you want to see accomplished. Biden was entirely ineffective at this part.
Besides, how was the policy approached in the primary? Biden's public option was sold as *the alternative to Medicare for All that could actually get done*. You don't get it done by pretending it doesn't exist.
Then, look at his reelection campaign. Did you hear anything about the public option during his reelection campaign? I didn't. If there was any time to revive it, it would've been for his second term. Especially with how important of an issue it was within the base.
I simply cannot accept the argument that it was out of pragmatism. It's just bad politics, and bad politics is the antithesis to pragmatism.
2010 was heavily attributed to the economy. The ACA was very far down the causes, if it was even a cause. Very similar to 2024, really, where I believe economical concerns have to be the starting point for any analysis of why the elections went a certain way. Anything beyond that... show me the evidence. When there's a global wave of incumbent governments struggling, any country-specific reason is hard to believe. People like to attribute an election outcome to their reason of choice when most of them were fairly irrelevant. Heard it repeatedly from MAGA in the months following the 2024 election. "This is why democrats lost!" applied to the most benign reasons.
Also, it's 2026 and a new health system won't even be on the menu til 2029 at the earliest. It'll have been a long, long time since 2010.
It's 2nd, but it's 2nd by a mile, so I think "very far down" still applies. What is the makeup of the 18% that said health care was the priority to them? Given the near 50/50 split on those who wanted it overturned compared to those who didn't, might it be fair to assume that the makeup of that 18% is also similarly split?
Compare that to the economy with 62% of people saying it was their priority. I have a feeling that the makeup of that 62% was not so 50/50 in favor of the democratic side. Unfortunately, voters love blaming the current party in power for economic woes, right or wrong. Given the historic nature of the great recession, I think it's what drove the historic nature of the 2010 midterm.
There's also historical (and modern) precedent for how fallout from economic issues punishes incumbents. Look at what happened in the past few years from COVID economic troubles. The US was not alone in the incumbent party getting punished... it was like the 40th democracy in a row to have it happen. Similar to during the great recession recovery years.
Medicare A or B? The current Medicare payment out of your wages does not provide current coverage. A pays for hospitalization, but not physicians or drugs. You don't pay for private insurance "instead". You pay private insurance because you need or want it. Medicare paid while earning pays for Medicare post 65. Then when over 65, the Medicare wage tax you paid over the years and may continue paying as long as you work, requires no additional insurance payment. B is optional, no need to pay it if using private insurance. Same for Medicare D. Would Medicare for all mean hospitals free for everyone? Paid from a current tax? Or would premiums be charged, but hospitals compensated according to the Medicare schedule? Would a plan B be offered to everyone? Would B receive a generous general fund subsidy as it does now. If Medicare B were the only one required to accept all without a limit on pre-existing conditions it would be expected to cost more for each patient. But younger people generally cost less to cover. Would the optional B charge the about $1200/mo that B sees /patient with its ~75% subsidy? Would price be scaled by age? Would the ACA subsidies apply?
A few additional thoughts. One of the biggest problems with today's system, such as it is, is the linkage of employment to health insurance. Ensuring that any transitional plan is directed at breaking this linkage is key. Second, a way to speed the transition to single payer is to build on something already in the ACA , mandating minimum medical loss ratios. If every two or so years, the minimum medical loss ratio was ratcheted up, eventually -- years, not decades -- health insurance companies would either get better or exit the business entirely. Finally, it's at least worth mentioning that some 600,000 people work in the health insurance industry. Their futures need to be taken into account.
Problem is that both Medicaid and Medicare depend heavily on MCOs - ie, insurance companies, many of whose "disgusting profits" are via their Medicaid/Medicare participation.
WE MUST MOVE PAST PATIENT BASED BILLING.
For example, the average emergency room visit costs $2,500 (with high variance). The cost of doctors + staff + operating costs + drugs + outside specialists per emergency room per year divided by number of patients served is $1,200. Medicaid and Medicare would save over $50 billion a year on ER costs if they simply paid each ER $1,200 times expected annual patient load (next year projections very accurate every year by every hospital) and bypass the MCOs entirely.
The Insurers would love it! They hate these villianizing, massively expensive hidden third party negotiations (and note that popular nonprofits BC/BS handle the Lion's share of health insurance).
Similar if Medicaid direct paid for EVERY PREGNANCY! Current is $25K billed per pregnancy ($30K total -6 mo to +6 mo) but actual direct cost is $6,000 per pregnancy. Directly paying for every pregnancy would save over $40 billion per year.
MEDICARE/MEDICAID DIRECT PAY ALREADY EXISTS (but is small).
SINGLE VOTE COULD MAKE IT HAPPEN. COULD BE REALITY BY THIS TIME NEXT YEAR.
Actually, would also need a vote to rescind ICE funding and restore safety net cuts in BBB - they approximately offset - and 80% of USA would approve.
As a retired small town family doctor, I advocate a federal national health program. Indeed, Medicare for All is the idea. But getting there by way of the buy in may be the most practical and possible--and probably the quickest. Getting to the end by the most expeditious means may be the principle.
I am a retired Internist who worked in Academic Medicine, Public Health, and finally Private Practice and there are a lot of tweaks which could be worked into the creation of such a system. First of all the exodus of younger people into the Public Option will drive up further the cost of the Private system. We as a Nation can no longer afford this high-priced system which leaves many with no coverage at all... Medical Bankruptcy is a concept unique to our American System.
"But look at which sector gets even worse ratings: the federal government. That’s deeply unfair to the many dedicated men and women who try to make government work for the people. Yet unjustified as it is, it’s a fact of life."
Also fair to say that this poll was taken in August of 2025, with Trump busy gutting the IGs and JAGs and firing all of the non-sycophants while installing folks like Hegseth, Noem, and Patel.
I would have voted "no confidence" at that time as well.
I would like to recommend The Fifth Risk by Michael Lewis to those who still feel that government agencies are bloated and ineffective; it reads like a thriller novel and clarifies the role and importance of "bureaucracy".
I previously worked in the federal government. I'm not going to pretend that every single one of my colleagues was diligent, hard-working, and competent. HOWEVER, most certainly were! Almost all worked with the best of intentions to serve the American public, ALL of the American public. The federal government has no larger percentage of lazy, incompetent, or bad employees than any private entity I've ever worked for. In fact, a large number of my colleagues were some of the smartest and most diligent professionals I've ever worked with. It is unfair and just wrong to label federal employees as a group, as it would be with any other group, and I find it sad that so many of our fellow citizens can't seem to understand that. Like any large company or institution, tweaks could be made to create more efficiencies and fewer inefficiencies. But at the end of the day, what matters is that, up until the first Trump administration (even more so in the second), it worked exceedingly well. Not perfect. Perfection in the realm of human endeavors is not possible. But exceedingly well considering the size of our country and the scope of its remit. Also, you make an excellent point about the importance of knowing when the poll was conducted. I certainly would have given lower marks during the purges as well. But historically speaking, the citizenry loves to bash the federal government. It's easy to criticize a monolith you don't understand or don't have personal experience inside of for all your woes and troubles. It's just the nature of the beast. I'm appalled at the level of civics education in our country. I feel the problem of the view of the federal government held by many could be improved somewhat with more and more rigorous civics education in our classrooms.
Agreed. I've worked in both public and private sectors. My experience is that public employees are, by and large, a little more diligent and competent than private sector employees.
I worked in state and county government--I was a public service careerist--and it was the same at those levels. Folks hated government until they needed it, and then were glad it was there. A conservative friend lost buildings on his ranch in a wildfire. No! He disapproved of FEMA and would not apply for funds. Then he did, and FEMA came through, and he was able to rebuild.
About healthcare: I'm on Medicare, and had difficulty finding providers before going on an "advantage" plan. No one wanted to deal directly with Medicare and thought their reimbursements were too low. My chiropractor is able to charge me just over $30 when her regular fee is $65. It seems like the entire cost/fee structure would have to change. A "buy-in" option might ease the path, but get ready for the anti-lobby battle of the century!
Did your rancher friend change his mind about government after his FEMA success or did he continue to vote Republican because they are “fiscally responsible and advocate for small government” claims we should all now understand were false?BTW I also have Medicare and a private Supplemental plan, which covers co-pays and deductibles of Medicare approved services. I live in a rural area and have not had any issues finding good care.
He may have. He wasn't like the conservative crowd we have now. He didn't always vote Republican, even. On healthcare, I now live in an urban area. Perhaps the system works better in rural areas--although when I lived out, I drove a long way for care. A "supplemental plan" isn't necessarily a Medicare advantage plan though. I hope you continue to get good care!
Lots of interesting comments! Medicare Advantage plans were introduced to, it seems, inject some of the benefits of private healthcare insurance into the system, expanded coverage options for example. The original idea sort of morphed & expanded, & grew more with each Congress. Now I see coverage options contracting, & co-pays increasing--depending on plan. In everything to do with healthcare, I can't get away from the dollar signs. Costs throughout the entire system just keep increasing without end. It's also worthwhile to mention that this Administration doesn't dare touch Medicare. Medicaid--which helps primarily children in low-income families, & the disabled--was fair game, & the courts have not resolved the issue.
Here's an idea: DUMP MEDICARE FOR ALL and reimburse providers at the MA rate. Fixed it.
Big Mistake--I MEANT DUMP MEDICARE ADVANTAGE!!! 100% SUPPORT MEDICARE FOR ALL!
When I worked for one state and with state agencies in another, I found much the same thing. Many worked hard, some were average and a few were there to get a paycheck doing as little as possible. Generalizing about any large group misses the mark at least as often as it hits it.
I feel the problem of the view of the federal government held by many could be improved somewhat with more and more rigorous civics education in our classrooms.
Sad to say, but schools can't even begin to compete with the propaganda spewing forth from every social media site. Plus, if a teacher actually tried to teach students how to analyze the propaganda they face, they would be accused of left-wing communistic bias. All it takes is ONE PARENT to complain to the principal and the teacher is toast.
All too true, unfortunately.
The federal bureaucracy has always had its own take on things but I used to be able to trust them to operate in good faith relative in that context. Now I have to look very carefully to see whether the GOPs political commissary have twisted an agency almost beyond recognition. This is much like the court system abandoning the presumption of "regularity"when dealing with the executive branch.
I read this excellent book during the first Trump administration. I believe that too many who seem to hold the idea the Federal government is bloated & useless would benefit from reading Lewis's book. If only.
Read that book too--EXCELLENT!
Thanks for bringing up The Fifth Risk, an excellent book and an easy read. I spent some of my career as a civil servant in Ontario, and Michael Lewis gets it in a way many don't. He has also written a second book, which I have not yet read, called Who Is Government, and a third due out in October called Blockers which will look at the DOGE catastrophe.
As a practicing and now retired physician who has delt with both "governmental" and private health plans as a provider and subscriber, my experience is such that I prefer the federal plan despite despising governmental control as it now is. Government is the PITS but there are some sections such as Social Security and Medicare health that have performed very well despite the political efforts.
The overturning of medical treatment by private insurances (ala United Healthcare) has led to many sour grapes and it is time for single payer health care to be offered as a public option.
Republican/fascist governments are the PITS.
Thanks for this reference.
Or, for that matter, any book by Michael Lewis.
Abdul El-Sayed advocates for Medicare for all and is against leaving what we have in place but adding a public option. He believes the public option will get loaded up with the least healthy and oldest people which Rs, insurance cos., big pharma, etc. will be able to point to as costly and inefficient. What can be done to ensure that doesn't happen?
Michael Lewis writes fine stories!
I would suggest that a great many more think government agencies are ineffective after the MuskRat was finished.
I'm convinced Musk DOGE'd extensive parts of the Federal workforce primarily to fire Black and other POC workers. Blacks alone made up roughly 20% of Federal workers, and firing as many of them as possible is probably something neo-Nazi Musk considers one of his highest achievements.
Not to mention the governmental agencies that were investigating his poor business practices.
GOP corruption is OFF THE CHARTS.
Lets hope Dem leadership keeps strong focus on how brazenly corrupt the GOP's Epstein class has become under Trump2
Ouch! So his applied racism was just the cherry on top.
A buy-in would have a much better chance of passing as a public option to be purchased on the exchange, for sure.
As more bought-in by choice, it is likely it would likely become largely "for all" but people like to feel they have options.
A public option would also cause the remining private insurers to behave since people would have a better place to go if they do not.
I think it would also open people's eyes to the fact that "low income" seniors pay a lot more for regular Medicare per month than they would for a regular ACA policy.
Now, of course, all one has to do is go near or over the 400% of poverty subsidy limit at the moment, and this problem is reversed since the GOP axed the fix that Biden had put in place causing premiums to spike and this was worse for those older and over the subsidy limit.
Obviously, if we had enough Dems to add a public option, we could also fix the subsidies once again, as well, and get rid of that income cliff.
On the ACA, I paid about 20 dollars a month and since I had no health issues, I did not have to be concerned about a large deductible and the free check-ups were a blessing. So it was much better for me than Medicare. However, to save money I sometimes chose private pay and paid up-front for some things because if they billed my insurer, and I had not met my deductible, I would get a much larger bill in the mail. Many places had super huge discounts for paying upfront and then no surprise bill either. I was amazed at how cheap X-rays and MRIs and some appointments can be, if one pays upfront. I simply would ask and not even give them my insurance card.
In contrast, Medicare is 203 dollars a month for part B for anyone making under 109,000 a year, so I now pay 10X more and no longer have free visits that contain any real diagnostics or lab work for free. Of course the deductible is far lower but then there are other out of pocket costs, as well, and not as much of a cap. To be honest, I will likely have to drop house insurance so I can afford health insurance and even after doing that actually using it is too expensive.
Thus, if it becomes a public option, they need to combine some of the good from the ACA like more of a sliding payment scale based on a percentage of income like the ACA has and once they did that for the exchange, low income seniors would be jealous and demand it as well. Free Dr visits that actually include diagnostics would also be a plus and out of pocket caps based on income would be a blessing too.
The average SS payout is abt 2,000 a month meaning many live on far less of a payment than that per month if that is the average, so 203 dollars + deductible and out of pocket and gap insurance is simply not remotely doable for most.
I would like to see a buy-in to Medicaid, as well, as a public option on the exchange.
People on Medicaid get no bills in the mail so some on a fixed income would choose that buy-in instead of Medicare even if the monthly buy-in was a bit more because there would be no surprise bills and no bankruptcy worries - none.
What a relief that would be.
You may not be able to go to the Mayo Clinic, but still, having no worries is HUGE.
That is what I would choose, for sure.
I have had private insurance, ACA subsidized when that passed, Medicaid and now Medicare and Medicaid was by far the best - the others are not even close. The objective should be "Medicaid for all" not "Medicare for all." I do not find Medicare very good, at all to be honest.
I am on Medicare, but a Medicaid buy-in would be my first choice. Then no worries, that is if they get rid of estate recovery law, as well.
“ However, to save money I sometimes chose private pay and paid up-front for some things because if they billed my insurer, and I had not met my deductible, I would get a much larger bill in the mail. Many places had super huge discounts for paying upfront and then no surprise bill either. I was amazed at how cheap X-rays and MRIs and some appointments can be, if one pays upfront. I simply would ask and not even give them my insurance card.”
The system is so badly broken it’s insane. How is it even legal to charge a higher price to people with insurance. We’d normally call that fraud.
Yeah. I found that too. I paid out of pocket for an MRI. It was $500. Same place same drs. reading it too. With insurance it would have cost me $1200.
Every year, providers, hospitals, insurance companies and Medicare negotiate billing price and reimbursement amount for every covered procedure. They all play games to protect their own money. Providers increase their price to increase their reimbursed amounts. Just one example: Congress sometimes tries to "reduce Medicare costs" by paying only a percentage of the agreed reimbursement amounts. Providers (including hospitals) understand this game and its effect on a patient. So they often accept a cash fee that actually covers their cost (with some profit) to avoid the administrative expense and time delay to get paid.
Your $500 MRI might have been billed to an insurance company at $1200, but the negotiated reimbursement rate might have been $500.
I don't know why it's legal, but I ran into the same situation here in New Jersey. My pharmacy gave discounts for seniors that were a much better deal than what I would've had to pay going though my Medicare plan.
A big part of the problem is that (a) there is no health care system (“sector” is more like it) and (b) what’s there works just well enough for just enough people just enough of the time so as to make sweeping reform such as M4A very difficult. Call this broken if you want, but tens of millions of people will have no idea what you are talking about.
I think it is legal to charge out of pocket payers less because they can claim they are saving on processing and admin costs, and it is true. In addition, if an ins company does not pay they would prefer not to also have to bill you on top of that (more cost and work for them).
So, they have a good argument to say that it is not fraudulent.
In fact, they might get more of a payout for creative bill coding if they were fraudsters and prefer to bill insurance, so maybe we might think they are even more legit for offing a discount to make their headaches go away.
They bill the insurance what is allowed and needed because they know a certain percentage will never get paid or will get paid only a fraction of the cost, etc.
However, one can’t pay upfront for Hospital stays as they are too expensive although I did to pay upfront for ER visits. So, insurance is needed, etc.
If the admin costs are the difference between the cash price and the insurance price then all the more reason to reform the system urgently.
These sorts of things don’t make sense in a functional system.
Well, it will always be more expensive to bill someone after the fact, as well, even of there is no insurance and also an increased risk one may never get paid too. It seems to be a natural part of doing business regardless although insurance seems to perhaps have more hurdles. It is not unusual for business to offer some pay up front, esp with cash, discounts.
It’s rare and it makes little sense in a medical setting.
One of the consequences of permitting this billing is that people who are denied coverage are left with a higher bill. That’s extremely unfair.
it creates a system where hospitals really just bill whatever they feel like. That’s not optimal.
Ultimately patients and taxpayers pay for any complexity in medical billing. Fixing it is cheaper than letting it continue.
Medicaid is partially funded by the individual States. The quality will vary from State to State. Some States call Medicaid by another name; people in those States don't even know what they're getting.
Medicare buy-in sounds good, but ignores the financial death spiral that would ensue. A public buy-in is false hope, for the same reason health care in general needs to be seen as a public good: 80% of people use 20% of health care, 20% of folks use 80%. Insurance corporations understandably don’t like paying for health care, so they’ve become expert in covering the 80%, avoiding/dropping the 20%. A public option Medicare buy-in would end up covering the 20%, meaning it would likely combine high premiums with restricted coverage to survive. Plus a public option leaves the extreme level of bureaucracy currently in place. So, a public option would reinforce the (false) belief that government funded care is bad care — not a pathway to Medicare for All.
I suppose you do have a point. AZ (where I lived at the time) had expanded Medicaid long before the ACA came along even though it is a red state, so they had a very good system in place. The voters there via voter initiatives often do very liberal things but for some odd reason often put a large majority of republicans in the state legislator who would then try to undo what the voters had passed by ballot initiative with a huge majority. Thus, it made little sense. I think there was too many who listened to the likes of Limbaugh and watched FOX, but as often the case when you ask them about what they actually wanted, it was what the Dems were offering so there was a mismatch as is often the case in most red state and purple states. I answered your concern about fraud by answering Ronan above who was concerned about pay up front being fraudulent as well.
So, people should be able to choose a public option that suits their needs, for sure.
Well, there was a lot if good and needed stuff in the ACA, as well so to me, all 3 need to keep the good parts and make a new and improved version of Frankenstein's Monster.
They could. One is means tested (and now fraught with insurmountable paperwork) and the other is not. But, if the hybrid was sliding scale and included categories for those previously covered by Medicare, why not? This is probably the easiest part of it.
The two systems are operated under the same roof on the federal level, CMS, and each state’s health services departments. Merging the separate offices within these systems would require some doing—as in, cooperation amidst fear of purging positions.
It’s my understanding that Medicaid provides broader coverage in terms of services, but that may be state specific.
It wouldn’t surprise me at all if health policy wonks don’t already have at least a scaffold for implementing this already written and ready to elaborate on, depending on how the legislation is written.
In his last NY Times interview this past May, Barney Frank advocated for a somewhat different, but still incremental, approach than Dr. Krugman has discussed in this post. He suggested lowering the age of Medicare eligibility from 65 to 60. "You could do it right away, and it would work, and it would build support for going even further." This is the "thin edge of the wedge" approach. Frank was critical of people on the left who want to immediately create Medicare for All; critical because he did not think it could happen all at once like that. Essentially, it would be too much, too soon. https://www.nytimes.com/2026/05/12/us/barney-frank-congress-democrats-advice.html Whatever you think of Barney Frank, both his and Dr. Krugman's approach would be result in a lot more people getting coverage. A good starting point.
I agree with Scott.
I do, too, but just wanted to point out that there are other incremental approaches that could work.
That won't solve the problem.
If everyone is required to have one-payer insurance, and a public option. there will be a broader financial base, giving economies of scale to the public system. And less administrative waste.
Medicare Buy-In is the way to go. What would it cost companies and individuals per person? Has anyone done the math on estimated monthly cost per age group? One thing that never gets talked about is how much Americans are locked into their job/employer just for the health insurance. So many Americans would retire before 65 except for the $1500/month monthly premium costs. This is not the case in Europe and other countries with national health insurance. Americans think we are so “free” but most are locked into their jobs due to the lack of a single payer system.
As you said a lot of people in their 50's or early 60's would love to retire (or have to due to ageism or heath issues) or move to a part time. However the ACA marketplace with it's high premiums for people between 50 and 65 and $1 over income subsidy cliffs (ask me how I know) make it difficult. Allowing Medicare buy in at 55 seems like a would make that possible for so many and seems like the smallest political lift. However even that will likely be fiercely opposed by the right and the insurance industry as they know it's a start on the road to Medicare for All. In addition business uses the insurance lock in as another lever to control workers and prevent them from leaving.
Here is a good video to go along with this piece. Taylor Swift Blocked Trump, but not El-Sayed from using her message, and what is his message?
youtube.com/shorts/z5yvqauPhWI?is=L5uvedm04c8zHATq
I agree with Scott.
Scott:
I agree. I am a retired school teacher. I am hanging on to my health as best as I can with the support of Medicare. My daughter is a well-qualified teacher but will pay a high premium evidently because of her age & teaching in a private school.
Agree, although I'm a person who's ready to jump into Medicare for All, I would try to be patient to let the sceptics catch up.
Also worth noting-- US MCR is administered thru PRIVATE INSURANCE companies (MACs) who are paid a % of total cost, so they have the same incentives to increase total costs to increase profits that other private insurance companies have.
Also info about the distribution of costs-https://nihcm.org/publications/the-concentration-of-u-s-health-care-spending
The top 1% of ppl cost 20% of the total; the top 5% are about 50%.
The bottom 50% are about 3% of costs.
Yet 77 percent of Americans with private health insurance report being satisfied with their coverage.
HOWEVER, subsidizing employee health insurance is becoming an ever more expensive proposition for businesses. Also, only about 60% of those employed have employer sponsored health insurance.
https://www.healthsystemtracker.org/chart-collection/trends-in-employer-based-health-coverage/
A good start would be if folks understood what a misleading ripoff private insurance Medicare Advantage is...looks good in the beginning, but once you're sick, surprise! You're not covered.
My partner did a lot of research when it was time for him to sign up for Medicare and that is also what he discovered. They make it sound like a great deal but they can really limit your care. They are companies doing what they can to increase their profits, not improve your care.
The problem with straight up Medicare is there’s no out of pocket maximum. 20% of a lot is still a lot to pay. That’s one reason why some go for an Advantage plan.
I had advantage from 65 75. But I used it very little so the company got to keep most of what the federal government paid them to cover me. I have been very fortunate. So was the insurance company!
OMG, I have had a nightmare experience with that, which I will write about when I have the energy.
It seems to depend on the plan. Don't just look for the cheapest. Look at your needs and plans available in your zip code. And don't get a plan assuming you will never need xxx. On Medicare I had DVTs, a hip replacement, a pulmonary embolism event. On my Advantage plan I had two surgeries, a knee replacement, two heart attacks, and tons of drugs. I was never not covered. Though practices do ask me to identify the specific Advantage plan and then seem relieved when I name mine.
Exactly what plan do you have please? Folks should know.
It's an employer subsidized plan for retirees.
It is not a plan available to the general public, correct? How unfortunate.
I have a similar plan and very similar medical experiences with virtually full coverage. There are good Medicare Advantage plans available.
Are these good Medicare Advantage plans available to the general public? It would be very sad if they're only available to the lucky few...
Another reason to support Medicare buy-in for all. I have Medicare (I'm old) and I'm very happy with it and it's affordable.
Kaiser has been pretty decent, but you sometimes have to push them.
Wife and I also have Advantage plans through our employer. I've not a had a problem, but the first thing I did before signing up was make sure that all my doctors and all my prescriptions were covered. The first time I'm denied for anything, I'm gone.
Check to see if you can switch to straight Medicare from a Advantage plan. I don't think that it is always possible.
A real plan gives everyone the same coverage.
That is the advantage of a real one-payer system.
If you don't give options, every imperfection is the fault of the oppressive government. Complaints are tempered when alternatives are offered.
Giving options in the govt plan is a very bad idea.
It increase administration costs, and requires different fees for the different options.
There is always the option of private plans (which will cost more), or private supplementary insurance.
This will protect the govt plan from accusations of unfairly priced differences.
Note that states could and probably will participate as well. That means there will likely differences from state to state, both in potential fees and benefits.
But the federal govt should set minimum conditions.
States that don't want to participate will likely feel political pressure from their residents.
How it works (and always has) in Canada is the federal govt and provinces negociate the minimum requirements each year. Gradually this minimum is increased.
The federal govt uses its' financing for negociation, since health is in the provincial jurisdiction, like it is in state jurisdiction in the US.
The provinces are free to a charge fee (or not) for their contribution. The conditions have always included reduced or no fees for lower income users. Most provinces now charge no fees for their residents, with a few exceptions.
Employers which offer health insurance for their employees generally use the public plan, with supplements from private insurers. To the employee, it is just an employer plan.
Gov't plan can be the gov't plan. It needs no option except maybe to retain the A, B separation. People are used to that. But a private plan option that has mandated minimums, but allows for additional coverages as seen in some employer plans (e.g., Lasik, Botox, gym) would help keep the gov't plan honest. The gov't plan would then not be blamed for every imperfection. Why the states should be involved tilts to Medicaid. Medicaid is a super opportunity for fraud as evidenced by billers getting extremely wealthy off its payment practices. States, especially, the poorly run and poorer states, when up to 90% of the billed cost goes into the state economy from Washington often seem to welcome the fraudsters at least by not funding watchhdogs. When a doctor connected to a funeral parlor is billing $$millions$$, sometimes triple digit patients/day, you'd uh thunk the practice would not continue uninvestigated multiple years. And you can always buy a pardon if it's just Federal Law.
But the pay for services (procedure maximums) and paperwork requirements for Medicaid and Medicare seems to be offputting for some providers. When I lived in NY one complaint from a practice my wife worked at was the frequent appointment no shows for its Medicaid patients. They had no skin in the game. Some did not bother to even pick up a phone to cancel. Others had transport problems. Why there is not service for practices to handle billing paperwork is telling. The burdens must be unreal.
I have MA thru a smaller, regional non-profit and have zero complaints. Great customer service and never had an issue with a claim (and I've had many in the past 12 months). MA gets bad press but I think it's from the practices of the large national groups denying claims.
I have MA with Aetna. The only complaints I have had is that they denied my second Shingrix shot. They also want to send one of their health specialists out to my home, instead of having me see my doctor for a real exam. I ignore those calls.
Speaking of which, they just called.
May I sympathise with you. You seem to have been very unlucky with your health. I hope things are improving.
I totally agree with you, second chance. My husband has had multiple illnesses and surgeries. We’ve never had a problem. Ever.
I have Medicare Advantage with Kaiser of Northern CA. Super happy with them. They are big enough that as an HMO they do everything in house. Never, ever do their in house doctors think/care about costs. One thing I am concerned about is that they do pile up diagnostic code presumably so they can get higher per-capita payments from Medicare. I've read that this is rampant in the Medicare Advantage industry, and I'm not happy about it.
I think the biggest scam is the in-house visit to look for upcoding excuses. Leave it to the clinicians you see.
That said, the upcoding is by the numbers. We need some kind of control. I have two conditions of by the numbers heart failure (and some other medical history conditions that require vigilance), so upcoded on 3 scores (after 2 MIs), but no restrictions on my activities, except for things like sky diving and contact sports. I do miss the rugby, but the skydiving . . . . . .
Members of Congress were already hearing that from constituents in 2001--four years after it was created. In rural areas, people had no providers available. It's ideology-driven and makes no sense in health care.
Most people think any insurance is just fine. Until they need to use it!
Many seniors (including me) opt in to Medicare Advantage for one reason: Regular Medicare has no maximum out-of-pocket limit. If you get some really major medical problem that can break you. My Medicare Advantage (the nonprofit Health First in central Florida) has a $3,400 out-of-pocket maximum, and I have to say, very good service too. But if regular Medicare would institute a maximum for out-of-pocket expenses, I dare say that there would likely be a rush to regular Medicare and an abandonment of Medicare Advantage by many, many people. I suspect that the insurance companies likely have had a hand (i.e. lobbying dollars) in making sure that Medicare has no OOP maximum. That one thing could make a huge difference. BTW, you may have noticed that a few years back Congress passed a bill to limit OOP costs for drugs to $2,000/year. It was going to take a few years before it kicked in. Now that it's supposed to be in effect, the Trump administration is indicating that they want to repeal it. Yeah, what a surprise, huh?
Kaiser Permanente Medicare Advantage is an excellent choice if it’s available in your area.
My husband and I have always had Medicare advantage. I’ve never had any problems with it. When my husband was very ill and needed surgery, I was very glad to have Medicare advantage. I can’t say enough good things about it.
BTAM, I have read many comments on several different occasions similar to yours. I am on an Aetna plan in Oregon and have not had any significant problems except we have to choose providers "in network" or be charged a higher copay. In addition, Aetna covers up to 80% of some of my dental procedures, whereas Medicare never covered any dental. And finally, we no longer have to buy a private supplemental as was necessary with our Medicare. The premiums for supplementals seem to be pegged to age, and I have a hunch that it would now cost my wife and I (both mid 80s) around $300 a month each--over $7k a year.
I would rather not be participating in a program that is a ripoff or semi fraudulent, and am curious to learn more about your experience or knowledge of scamming MA plans. Would you be willing to share the gory details that you've experienced?
I too had MA through a major national provider, but have now switched to Medicare plus Supplemental (only because a life change afforded me a one-time-only chance to leave MA w/out penalty) and am much more satisfied. But let me list the ways I saw that MA can scam the system: 1) you’re pressured into recurring home health evaluations by a nurse or RNP that tell you nothing of added value beyond what your regular medical team provides and that MA providers then bill back as specialized home care, BTW, these must be so lucrative to providers that I’m constantly getting live sales calls to schedule these visits even though they cancelled my MA policy years ago; 2) you’re nudged into using their proprietary RX mail order supplier through teaser rates and easier access thereby giving them bulk purchasing advantages deliberately not passed through to you and they put local pharmacies out of business (the Amazon effect); 3) their summary of expenses divided up (MA/regular Medicare/yours) is totally black box and virtually unassailable leaving you to accept and pay their calculations on deductibles, copays and added charges that Medicare will not cover; your eventual OOP for any given transaction is also untethered in that the same visit to the same clinic in the same calendar year may have a different net charge to you based on the algorithm summing up your expenses to date and history of use so as to maximize their net year off take from you and regular Medicare. I could continue but if you’re happy with it, keep on keeping on.
I have never personally had MA; I have regular Medicare with a supplement. I have had cancer (recently celebrated 5.5 years cancer free) and a cardiac surprise resulting in 3 stents due to blockage. All I paid was co-pays for the tests and a co-pay for the ambulance. I have not had any denials and was able to choose Mass General in Boston for my cancer treatment.
Friends with MA have mentioned routine denials, required referrals, higher co-pays, and the hoops they’ve jumped through to get routine coverage and (in one case) to get off MA and onto regular Medicare.
Under Medicare, I do not have dental coverage, which truly is a bummer.
I will be the first to admit I am pleasantly surprised by the folks here supporting MA...I do not have any friends on MA who are long-term happy with their decision.
We have Medicare Advantage via Kaiser Permanente and it is excellent. We have never been denied coverage.
That Mick Jagger principle is doing a lot of work here.
Medicare for All may be the cleaner moral architecture, but a Medicare Buy-In may be the door people are actually willing to walk through.
The key distinction here is tactics, not values. If the goal is universal care, the path has to survive the insurance lobby, public distrust of “government,” and ordinary fear of losing what people already have.
More Medicare, less private extraction, and a transition people can recognize before they are asked to trust it. Get me?
Ok then.
www.xplisset.com
I like the idea, but that will mean that it probably won't be properly funded the way that public transportation and public health are in Germany, because everyone uses it. Medicare does not cover dental, which means people can still die due to tooth infections etc... and be ill because of poor dental care. That needs to be fixed. My mom is on US medicare, and I am when I am there, because I am covered by Part A. Otherwise, I get my medical care in Germany now. We are paying a fee based on income up to a ceiling and our daughter will be covered too, as long as she is in university or in an internship related to her studies.
I still think an option is better than what we have now and a door in. It would be great for Paul to share this with Abdul El-Sayed, and other candidates who talk about Medicare for all as a means for them to tailor the message with the goal is medicare for all, and the plan is to start with opt in.
Dental, vision, and hearing absolutely need to be covered. Who's willing to go without coverage for their teeth, eyes, or ears? An ounce of prevention.
This is a fundamental flaw with health insurance regardless of system or provider. Health insurance should unquestionably cover the entire body. It is all linked. Dental issues can lead to other bodily issues. Bodily issues can lead to dental and vision issues. They are not independent systems. It should all be included under one health insurance plan for that reason alone. Additionally, surely it would also improve continuity of care.
Absolutely. How do you think my mental health was when I was in crippling pain from a molar that needed a root canal? I was lying on the couch whimpering, unable to do virtually anything. Of course that affected everything else.
Yes, as if hearing, seeing, chewing and speaking are not part of human health.
What? ;)
I always "joke" that insurance will not cover vision care, but they will pay if you don't see the car coming and you end up in the ICU for months. Penny-wise and pound-foolish.
Exactly. The ACA forced more coverage and focus on preventive care, but still not enough. Moreover, as others have noted, it’s all inter-related. I’m diabetic. When I was diagnosed, they told me diabetes often affects 3 body parts: feet, teeth, and eyes. Sometimes issues with those are the first sign you may be diabetic. I’m supposed to get annual foot and eye exams. So why the !@#$% are my feet covered but not my teeth or eyes?
My Medicare Advantage plan covers vision care. Dental would be extra. When I was still working, my private insurance policy also covered vision. Both plans had co-pay requirements (my current co-pay is $40 per visit and something over $100 for an operation).
Given that by definition, insurance premiums exceed the cost of care, plenty of people prefer to pay for things like dental and vision care directly, knowing they are likely to save money in the long run, so long as they can afford the short term volatility. Same with way physical damage to your own car, or high deductible options for homeowners.
Insurance companies make deals with providers to charge less for the same procedures than they cost people without insurance.
Decades ago, my then husband tore his Achilles tendon and required surgery. We received a bill that for $10k for the surgery. Husband had become buddies with the orthopedic surgeon and called him in a panic. Surgeon literally laughed and told him, "Oh, that's if you didn't have insurance. Since you do, the insurance bills us and will end up paying $700 for the surgery. You're good!" (And I didn't forget an extra zero on the "$700.")
I agree that is one of the more damnable aspects of our current, Rube Goldberg healthcare system. It’s why people only chose to go uninsured in niche areas that are less mysterious.
Hear, hear!!
Totally, Jon.
Here is my first piece on dealing with Medicare. I need energy to write about how is has been resolved.
https://lindaweide.substack.com/p/the-world-is-not-designed-for-older?r=f0qfn
Today, I wrote instead about my Bugaboos with German Universities.
Not nearly as much as with US health care. I wrote about that a while ago when first finding out about my mom being thrown out of original medicare and put on an [dis]Advantage plan that did not cover her primary care.
https://lindaweide.substack.com/p/copy-us-health-care-is-like-rotten?r=f0qfn
You mean her policy didn’t provide coverage for the primary care provider she was using so she had to switch to another, right? Medicare always covers primary care but if your plan has a “preferred provider” list you have to choose from. I am confused about who forced her to change? Individuals on Medicare either enroll in traditional Medicare or opt to choose from the various Medicare Advantage plans. The only instance I can think of that someone else makes that choice for you is if your employer makes that decision for you if choose to get your coverge through them. I know several people on Medicare Advantage who still get employer coverage as part of their retirement benefits.
No. Some guy who got paid a fee, but did not get permission from my mom or me, and the Advantage plan he switched her to without any permission did not cover her primary care and it took me over 4 months to get her different coverage after I found out about this. I have the guys name, but have not yet called him to ask for proof that he got my mom's permission and Medicare has nothing in writing. My mom has dementia, so she could not have done this on her own. I am sure this is happening to a lot of people. It is easier for some stranger who is paid a fee to switch someone's medicare plans, with no proof whatsoever that she agreed to it other than his say so, than it is for me, the person who has legal rights to make decisions for her.
oh, that's terrible! Was this guy a Guardian? I've heard some horror stories about elderly people who get stuck with unscrupulous guardians.
That’s us. Every sick day we didn’t take while employed rolled into a post-retirement health care fund. But the catch is that only the employer’s preferred provider is available, which turned out to be medicare advantage plan with united health. It is generally decent coverage but quite limited for eyes, ears, teeth which are turning into major expenses for us. Still, it feels like most stuff (including my husband’s cancer care and my own rheumatoid arthritis) get well covered.
Argh. Will read. I'm in the Netherlands myself, planning to move back this fall. Health care is cheaper here but has many other problems. I need a permanent crown on a tooth the dentist estimates at €750. My good insurance only pays €500. I don't really have the other €250.
My last crown cost me considerably more than that, here in the States.
My friend had her sister come here to Germany to pay for her colonoscopy out of pocket, because it costs do much less here.
Oh, I paid $2400 for a crown in 2003 when I had strong health insurance as a federal employee. Insurance reimbursed...$40. I had other plans for that money, like a bicycle. But I'm not allowed to work in NL. If you don't have the money, you just don't have it. They'll partially subsidize health premiums, but not fully, and not other costs. I'm holding out until I can get employer-sponsored insurance in the US again.
Jon, Germany has out of pocket dental expenses too. However, I am finding the costs for my mom's out of pocket dental expenses right now to be much more in the US, since dental is also not covered in Medicare. We have an office in Chicago where they have their own in-house insurance plan, but that is more for regular care and costs around $600 a year which includes a check up and cleaning and some other things. However, my mom cannot use it, because she has problems that need more help. My aunt, who is also in Chicago said that she has always paid dental out of pocket until she joined a certain Advantage Plan that covers it.
The problems people complain about here in Germany with health care, like waiting for appointments is no different than I had in my health care in Chicago, at the University of Chicago Medical Center where our doctors were.
I wish you luck in your move back.
Agree... I live in upstate New York, and we have a terrible time getting timely appointments. The issue isn't about insurance, but provider shortages. I wonder if that's an issue where you are in Germany?
During their 14 years in power the conservative Tories underfunded the NHS. Today it is in such bad shape it has forced many people to turn to private health care — which is exactly what the Tories want.Just as Republicans her privatization/the “free market” is their magic cure-all. But if the Labour Government doesn’t fix the NHS quickly they will be blamed even though they are faced with serious budget problems caused by Brexit. The UK media has memory-holed the colossal Brexit mistake pushed by conservatives like Boris Johnson and far right leaders like Nigel Farage. Even the BBC, cowed by years of conservative threats to their funding, doesn’t bring it up when interviewing Farage:
“Farage collapsed the economy with Brexit, and faced no consequences’ – Stephen Flynn:
With the BBC facing criticism about the amount of airtime they are giving Nigel Farage, some awkward questions have started to emerge.”
https://www.thelondoneconomic.com/politics/nigel-farage-brexit-reform-snp-395783/
Theodora30, Glad that BBC is getting some push back about giving Nigel Farage air time. It is basically a means of spreading disinformation unless they refute what he is saying. German media does not do that with US disinformation I have noticed and I write my complaints.
I was really hoping Count Binface would beat him. That would have sent a message!
I have Medicare Advantage with dental and almost all procedures I get are denied. Don’t be fooled! They also will not cover regular medical procedures if you are outside your coverage area like when visiting out of state or going on vacation. Try harder to get what you need and don’t sabotage it because of fringe issues. Common goals are needed to get it passed! Worry of about fringe additions after you get the basic program.
Yes. I understand. That is what we are doing. Still, it took me months to straighten everything out. I have notes because I had to make so many phone calls. I could tell within the first minute if the medicare rep was going to be helpful or difficult, but I had to talk to whomever I got.
Yes, any future healthcare for all should also include dental and vision
Exactly.
So many seniors are so heavily in debt, thousands of dollars, because of dental bills. Evert time we save for a vacation, another dental problem arises, and we must use those savings to pay the dental bills
I am sure. It is one reason I left the US. I did not want to deal with the constant threats to medicare from the Republicans, and the idea that health care is a privilege not a human right. People told me I could not get into the German public health care system after retirement, but I did. I am a citizen, what are they going to do? I have asthma a pre existing condition which is better controlled when I live in a place with cleaner air. Yay! Still, private insurance does not like to insure people who have pre existing so I knew we were going to go for public, which is what everyone I know uses. It covers 90% of the population.
Yes, absolutely! I keep wondering what idiot decided that teeth and eyes aren't part of the human body. I have a supplemental dental plan for Medicare. It paid $479 on a $4000 root canal. Yahoo.
Hi Xplisset,
I think that your argument misses the more important point: healthcare is costly, it comes around when we least expect it, and both the diagnosis and the price tag of the treatment can be overwhelming.
As a doctor (retired now), I’d advise people to think more about getting through the acute situation (the diagnosis/ the accident), and to put your concerns about ‘choice’ of physician/ whether you get a private bedroom or not, to the back of your priorities.
The costs in the US are exceptionally high, and US Americans do not get better care.
The costs are rising and will rise further.
Paul’s arguments are partly about what system might keep healthcare costs more sustainable, and partly about what degree of mutualisation of risk Americans are broadly willing to accept.
Regards,
Anthony
One reason the cost is so high is the tort system. Lawyers and their lobbyists will tell you that if you get affected by a medical mistake, you deserve your day in court. I don't want a day in court - I want to be fixed up. That's also the reason hospitals are run by Byzantine labyrinths of detailed procedures for every "what if?"
We have to think about both. It would be nice if it were simpler. I have my mother covered the best I can, and unfortunately, insurances we paid into will not follow her out of the country.
Yes, a buy-in would have a much better chance of passing as a public option on the exchange.
I am not sure what state you are in but there are Medicare Advantage plans, some free many cost with buy ins for dental, eyes, etc. You have to read all the small print. The open enrollment periods are in the fall
I have heard such horror stories about Advantage that it is hard for me to do, but I will look more closely.
It’s worth looking into. Still not the greatest, this year I had an eye check up included but the glasses were only covered nominally. That’s why it is important to read the small print and listen to Paul Krugman’s Musical Coda today. Don't call the telephone number from the companies which advertise in-between local news, if you have a Senior Center that is close to you try asking if they have a representative there who can explain the plans, so you don't get involved with anything untoward. Ask questions get information before you share any personal information.... A lot of caveats, but you want to gather information before you give personal information. Some states produce a list of Medicare advantage plans which are available in your area which you can view online .That's my take on how to search for the correct product best regards
We have the same kind of coverage for eye exams. We just take the prescription to Costco to get glasses instead of getting it through the ophthalmologist’s office.
I used to do the same, but the local Costco provider puts that "blue-blocker" tint to all their lenses now. Since my major hobby is taking and processing photographs, I only deal with optical outfits that provide me with clear glass lenses.
Similar I went to Warbly Parker. Three pairs for the cost the recommended opthalmologist wanted to sell me one for…
I know a lot of people who have switched to Medicare Advantage plans and I am covered by MA through my spouse’s retirement benefits. No one I know has switched back to traditional Medicare, which you can do during the yearly enrollment period. I have also read horror stories but no one I know has had problems. I do wonder if it depends on which company you use or what state you live in. Apparently states play a role in Medicare Advantage oversight so I wonder if that is also a factor in how reliable coverage is.
If you don’t choose a Medicare Advantage plan you need to pay extra for Medicare Part D to get coverage for prescription drugs. Many people also buy private Medigap plans to cover deductibles such as for hospital care. Medicare Advantage plans combine these kinds of coverage into one plan but you have to look carefully at that the different plans offer.
It’s very confusing.States offer free, non-biased advice through their State Health Insurance Assistance Programs (SHIPS).
The National Council on Aging offers advice on how to talk to about choosing a plan.
The AARP also offers advice:
https://www.aarp.org/medicare/managing-costs-coverage/choosing-plan/
excellent advice and link. thank you
Wouldn't the affirmative 'choice' component, where you have to decide & choose it, help reduce any conspiratorial blowback from the far right as well?
You know, you move 350 million people from one 'folder' to another 'folder' and you're bound to cause enough problems to create conspiracies. You let people 'choose' and you now have personal testimonial as to how good of a choice it was.
Central Limit Theorem question, because let's face it, Insurance risk is a CLT question: would the gradual move allow a 'Medicare for All' plan to adjust gradually as they work to find what the CLT says real 'risk' is for each demographic group? Or would the people who 'choose' have characteristics/patterns that throw the average 'off'?
The fact that Walmart etc minimize work hours so as not to provide health benefits to staff is part of the problem. Employers should be taxed per work hour for every employee who they do not provide coverage. Those taxes should be used to subsidize coverage for workers at those companies. The freeloading by major corporations with respect to insurance and other externalities is despicable.
Please do an economic analysis of lowering the eligibility age for Medicare, incrementally. Since Medicare is the most popular government program, expanding its current format to more people would also be popular. Doing so would reduce or eliminate the fear factor and likely generate a political groundswell for Medicare for all. Seems far simpler than a buy-in option, which would create a new tier to the health care system rather than just expanding what already works.
We need to demand that employers like Walmart, Starbucks, Amazon, first pay a living wage and then supply healthcare.
They need to do both - living wage and insurance. They can do both. They choose not in order to funnel the money up the ladder to execs, legal teams, consultants, shareholders, and the like.
I’m in favor of fining every company double the amount the government spends to support their employees. That would increase pay and benefits quickly enough.
"But look at which sector gets even worse ratings: the federal government. That’s deeply unfair to the many dedicated men and women who try to make government work for the people. Yet unjustified as it is, it’s a fact of life."
We've had half a century of Republicans telling Americans to hate their own government. Indeed, starting with Ronald Reagan, every Republican president has made it a point to tell voters how much he hated the government of the United States. And once in office, every Republican president has done everything he could (and in the case of Trump, MUCH more than he's allowed) to disparage, damage, or destroy the government of the United States.
So is it any wonder that people hate their own government? The implications for implementing Medicare for All are obvious. But the implications for the continued existence of the country should also be obvious.
People who say government is the problem should not be allowed to hold government positions. If you or I told a prospective private employer in a job interview, "Your organization is the problem," I doubt we would be hired.
There’s a guy in our neighborhood that puts the same sign up every election. “Two term limits for politicians: 1 in office then 1 in jail.” It confounds me. If that is how you feel, then work to make it better, don’t disparage it and turn it into a joke. It is so cynical and just perpetuates the legitimate problems that do exist. But it will come as no surprise when I also inform that it is always next to a bunch of signs for right wing, MAGA type candidates. So, the irony is lost on no one that he is voting for the very criminals he seems to be complaining about.
There is a failure of imagination at work here. People who hate the government or put up cute little bumper stickers like 'taxation is theft' have no idea what would happen to them if our government disappeared. Basically, all their rights would disappear with it. People need to watch The Postman, a post-apocalypse movie that shows pretty clearly what life is like after the government collapses. I watched it last back in summer 2024, and I actually felt a wave of fear thinking that Trump could win the election. Well, here we are... though we're not at 'the Postman' levels yet, thank God.
Yes, and complete ignorance about history and the evolution of how we got to more government services providing for the greater, common good. A simple example is the fire department. Once upon a time, if you didn’t pay for private fire insurance, your house might burn down…unless you could rally enough neighbors to try and help put it out…which brings us full circle to why it’s not about the individual but the group. We need one another to have a successful society and government is the framework for making it work. That doesn’t mean it’s perfect or that change won’t need to happen as life evolves, but we can’t have successful society, be successful individuals, without it.
The fire department situation was the case when I was a boy in Knox County, Tennessee. I recall a house catching fire a mile or two away from ours. They hadn't paid for fire protection. The fire department came and watched it burn, while making sure it didn't spread to the neighbor's property.
Hear, hear!!
"We've had half a century of Republicans telling Americans to hate their own government."
And a half a century of them, whenever possible, doing their best to make it hateful.
But what do people really think it means? "Keep the government out of my Medicare!"
The problem is the clueless people who claim they want good government and then vote for a party that has pledged to drown government in a bathtub. Then they appoint incompetents and corporate insiders to run government into the ground. When they ultimately fail, these same clowns claim that "government is the problem".
The question of hating the government should be two different questions. One about the government officials you may have had direct contact with and the other about those who wield power broadly. I’m fine with the letter carrier and the lady at the social security office. The government officials that make the news are another story.
Very good comment! The word “bureaucracy” is a label purposely misapplied by both Rs and Ds to castigate government employees…local, state, federal…as lazy, inefficient, uncaring and incompetent.
It’s a politically-based label and like all such labels is used to attract votes for “Change”…AND IT’S NONSENSE!
Every organization, corporation and government dept is a bureaucracy!
Every. Single. One.
They all have the same pyramidal structure. And when any organization fails, those nearest the top POINT DOWNWARD and blame those below…the bureaucracy (or ‘workers’) who are there everyday doing their best to succeed DESPITE the failures and incompetency and, too often now, the outright criminal actions of their leadership.
We pay $1800 a month for medical insurance that covers nothing and the insurance co will - and has - denied doctor recommended procedures. He'll yeah, Im in for Medicare buy in.
Of course that $1,800 pays for something. It pays for insurance CEO salaries and stockholder dividends.
I often think about this in passing, never really crunching the numbers. I think because of our extremely convoluted and confusing system, Americans have an odd view and difficulty even really understanding our own health insurance. We have monthly premiums but it is still not always, usually never, clear what we will actually pay because it can vary so wildly depending on the plan as well as the issue. Is it routine, emergency, chronic? In or out of network? What is your copay and deductible, individual and family? Does your plan cover blood work, imaging, transportation? That is just the tip of the ice berg.
Good point, "We pay $1800 a month for medical insurance that covers nothing."
So many focus on WHO pays and miss that the total cost for providing medical care in the US is way too high and growing at an unsustainable pace...
Am I correct in inferring from this that reforming the market for medical care (limiting monopoly, transparent pricing, etc.) would be a harder sell than expanding Medicare?
My wife and I are highly satisfied Medicare enrollees. Because our retirement income is higher than average our premiums are subject to income related surcharges, resulting in a fairly stiff total yearly bill. Making people with higher incomes pay more is a concept that should be carried over into a Medicare Buy-in.
Woke is a good thing
"Woke," when aligned with empathy and compassion, is defined by many as being aware of social, racial, and political injustices, aimed at fostering a more caring, inclusive, and equitable world. It emphasizes understanding the human behind every story, listening deeply, and actively working to alleviate suffering.
• Awareness & Action: Originally rooted in awareness of racial injustice, "woke" has evolved to represent a broader consciousness of marginalized groups and systemic inequalities.
• Empathy as Strength: Proponents argue that empathy—feeling the pain of others—is not weakness, but rather a strength that guides a desire for a fairer society.
• Compassion in Action: While empathy is feeling the suffering, compassion is the desire to relieve it, and kindness is the action taken to do so. Supporters see this mindset as leading with love and humanity.
Ultimately, being "woke" is a conscious, ongoing effort to recognize one's own biases and to care for the well-being of all people, regardless of their background.
Now, who could possibly oppose such a beneficent course of action? Possibly only those who are filled with anger, hatred, jealousy, envy, paranoia and ignorance.
Say it loud,
I’m woke
And I’m proud!
THEY should try it.
Please: Resist. Stop cooperating. Stop spending. Stop the fascist takeover.
Thank you for restacking, and sharing, to help Spread the Word!
Thank you for making those points about "woke". I'm with you!
I have a book called WOKE, which I used to teach the meaning of the word to my fourth and fifth grade students. It is basically teaching the idea that WOKE means you are alert to what is going on around you, something that non White people, and women always have to be. Although, I am currently living in a country that was at place 15 on the Global Peace Index, then dropped to 20 these past two years, and now, in part thanks to the AfD, has slipped down recently to place 28 on the GPI.
https://www.visionofhumanity.org/maps/#/
Thanks for the like and restack. Much appreciated.
How is being woke all that different from being a good Christian? In both cases, it’s more of an aspiration than an actual state of grace, with most of its acolytes falling short.
"We grew up on Scripture and the story of the rich man and the beggar Lazarus was powerful. The beggar lay at the rich man’s gate, hungry, covered with sores, and when he died, angels bore him to heaven where he sat at Abraham’s side, and when the rich man died, he went to Hades and sat in flames. He looked up and begged Abraham to send Lazarus down to touch him and ease his pain and Abraham told him to go to hell. You don’t need a Bible scholar to figure this story out.
A wealthy country with vast farmlands allowing its own children to live on the edge of malnutrition is, if I read Scripture carefully, a damnable sin. Malnutrition of babies can lead to lifelong disability. Think on it." - Garrison Keillor
Agreed, but there's no possibility of progress unless we win elections. Forget the irredeemable FOX-GOP cult; it's any voters in the middle, for whatever reason, who have a "better nature" that can be appealed to, who'll make the difference.
And I think that for those people just the language of wokeness is a knee jerk turnoff. No one, including decent people who haven't had the time or opportunity to reflect on their beliefs, likes to be condescended to or be given the impression that the life they've been living has been a lie.
So for me, 'it's the language, stupid." Best exemplified by the term "Latinx." Empathetic people are supposed to be able to "stand in other people's shoes," yet Latinx advocates seemed to have zero concern for how (especially ) Latin men would react to the suggestion that the very language of the culture they come from and may still speak makes them sexists who need to be reeducated?
Using simple and direct language appealing to one's better self is the way to win, and winning is the only way to make progress possible.
Your words speak both to the heart and mind. If “woke” is as you have it defined, then yes, what reasonable person would not be in agreement with you? However and sadly the term has been so badly tainted that I would use the word “awakened”. As in I have been awakened to my interconnectedness with the whole of humanity. I have been awakened to a desire to cooperate and contribute to the betterment of society as a whole. I have been awakened to the sufferings of others. The challenge now is how to awaken those who would rather remain in the dark. Who would rather cause harm. Or those who are too fearful to speak out. Still, your words resonate and my sincerest desire is that, like seeds of hope are spread far and wide. Thank you for your contribution.
The concept of “woke” originated in the African/American community and that’s why the magats hate it so.
I think that’s likely right, as with a lot of the MAGA mentality.
Oh I know of it’s origin. And the original meaning is to stay awake as the good book says. Stay awake for you know not the hour when…it was as a cautionary note to the community but it’s become so toxic that like many other labels I prefer to speak plainly so as to reach out to all who can hear. Labels are just like taglines and headlines. Distractions that take you away from the meat of the story. Thanks for your reply.
That coda is a great reminder - we should get to it and seek to find common ground that would allow us to have a healthier (and less worried) nation.
Paul - yes to universal coverage, but Medicare is NOT the right option - Medicaid is.
Here’s why Medicaid for All makes much more sense.
TL:DR - Net is Medicare for all sounds great until you think thru the details
- Medicare coverage is convoluted and confusing (e.g. X days in rehab allowed then no coverage for nursing home care),
- has little experience with families, moms and babies,
- requires/involves supplemental coverage from commercial payers
- Medicaid includes some state funding which makes it much more politically palatable
Medicaid for All will spread the cost of universal coverage across states, reducing federal financing requirements.
Medicaid is a state AND federal program; States provide a lot of the funding for Medicaid; on average the Feds contribute 63% and states 37%. This is critical, as Congress will want to spread the cost of a Single Payer solution and there’s no better way to do this than require states to pony up big dollars [State contributions vary based on a state’s average personal income relative to the national average; states with lower average personal incomes get more federal dollars.]
Medicaid is already built to cover everyone. Medicad covers people of all ages, Medicare is very much elder-care focused.
Adapting Medicare to handle everyone from newborns to elderly, maternity care to pediatrics will be difficult, time-consuming, and expensive. Medicaid does all this and more - today.
Generally, Medicaid is less expensive than other “systems”.
This is due to much lower provider payment and significantly lower administrative costs. Yes, this means providers are going to be paid less - in some cases a LOT less.
- that includes device manufacturers, home health care agencies, drug manufacturers, facilities, physicians…
Medicaid member satisfaction is pretty good; access to care is not much of an issue.
Medicaid-based Exchange programs are much more successful in the Exchanges than commercially-based plans.
The Centenes et al [Medicaid-based plans] understand the demographics of the uninsured, have lower medical costs, and already have provider networks, customer relations operations, workflows and processes set up and operational. At the end of the day, lower cost wins - and their costs are lower.
Medicaid is a simple, fully-integrated healthplan.
Medicare’s alphabet-soup of Parts A B C and D - plus Medicare Supplement - is confusing and convoluted, with different payers often covering the same individual. This increases administrative costs, member hassles, and decreases quality of care (co-ordinating pharmacy and medical care between different payers is problematic at best).
Managed Medicaid plans are working.
These plans currently exist in most states, and many have been able to deliver excellent care at lower costs through innovation and very tight focus on outcomes. One example is using paramedics to deliver care. [disclosure - I sat on the board of Commonwealth Care Alliance, a Massachusetts healthplan that serves dual-eligible members]
Good points. Thanks.
Welcome!
I don’t disagree with you on the merits. But the messaging will never work. Medicaid is irrevocably associated with being poor and low-income, and no one wants to be considered to be so needy as to qualify for Medicaid. I expect a lot of middle-income people who could benefit from it would be ashamed to join. We are a very class-based society.
Thanks Ann.
couple observations - first most of the lives covered in the Exchanges are in what is in effect Managed Medicaid plans.
Second it's pretty easy to just change labels - as Molina, Centene and others have done - to make middle-income folks comfortable.
The messaging is the easy part - getting politicians to grow a backbone is a much heavier lift.
be well Joe
Not only that, but the individual States pay part of the costs. That ranges from 21.9% in New Mexico to 43.8% in Massachusetts. You will never get this through as long as the States have to foot part of the bill.
Hear, hear!!
thanks Anthony
What about lowering the age of access incrementally to 60 or 55, and measuring the feedback from that swath of the population to gain momentum?
YES YES YES!! I am literally counting the months until I turn 65 ... and my COBRA premium is $800/month
My concern with that approach is that asking citizens in their 20s and 30s today to pay noticeably higher FICA for 10 or 20 more years before they are eligible to receive the insurance is likely to face considerably more resistance than letting them buy-in right away.
I suspect that in the 1950s and possibly the early 1960s, when middle class economics were better, it would have stood a better chance.
Also, this approach essentially ignores the problem of a lack of preventive care amongst younger people, which can help avoid many far-costlier conditions as they age. Getting younger people covered ASAP should be a high priority for any reform option.
They should do it in a way that fica only goes up if your job healthcare premiums go down to compensate. This actually would be easy to do if we moved the young us to single payer as well.
Those 2 "if"s seem pretty big to me..
Wouldn't Medicare for All also make US companies more competitive, because they wouldn't have to pay insurance premiums? If Medicare were mostly funded by taxes on corporations, couldn't those taxes be less than what they currently pay in premiums? And wouldn't the economy as a whole be more productive without a whole industry (i.e. health insurance) devoted to denying people healthcare? And would another incrementalist option be to decrease the eligibility age of Medicare by one year every year or so? Or, as a cheaper option, add in 20-year-olds each year, so that all will be covered in 45 years without upsetting people who are happy with their current insurance? These are not rhetorical questions; I would like PK to address them.
The last sentence of Professor Krugman’s post is the key. Elect people who are committed to providing Americans the healthcare they deserve. Hopefully voters in the South, Upper Midwest and places like Ohio are paying attention. I’m not holding my breath.
Cook Political Report just shifted 2 US House races in Ohio from Safe to Likely Republican yesterday, explaining that both Sherrod Brown (D) and Amy Acton (D) are likely to win their races.
How do those two clauses go together?
the statewide and congressional races? I think the point is that the overall atmosphere in the state is shifting toward Democrats, so if the ones at the top of the ticket are winning, there's a good chance they'll pull some lower-ranking Dems across the finish line with them. I'm not connected to CPR, but they're longtime, credible political analysts.
Ahh, I misread the beginning. My brain read likely R and thought it was moving right, not left. My bad. Thx.
You didn’t misread. It actually says “likely Republican.” Probably ly unintentionally.
I think "safe" is considered stronger than "likely". So the districts were formerly "safe" for Republicans, but now that expectation has been lowered to just "likely"; i.e., Republicans will probably still win, but the Democrats are going to give them a run for their money.
That makes sense, although it's a bit opaque way of saying it.
Among political analysts, those are standard categories. A given race is classified as Safe, Likely, or Lean for either party, or a pure tossup. Admittedly, it's a bit of a niche most people aren't familiar with. I looked on their website, but the explanation is behind a paywall. I tried to screenshot the email but couldn't paste it here. There are so few competitive House races anymore that the vast majority of them are Safe Democrat or Safe Republican.
Neither am I.
This looks very much like Buttigieg’s “Medicare For All Who Want It” proposal, which I fully endorsed at the time.
The point I’d like to see addressed is as follows: today I, and tens of millions more, pay for Medicare but don’t use it. I use instead, and pay for, private insurance. The net result is that I pay into two programs but use only one. Assuming both programs are actuarily sound, my private insurance collections and benefit payments per covered beneficiary are the same, but Medicare collects a much smaller premium per payer than the benefits it pays to patients. Moving people into Medicare Opt In would mean having more covered individuals with essentially the same revenue, and that won’t work. You’ll need to increase the premiums everyone has to pay.
Yes, the new beneficiaries would offset the Medicare tax increase with the savings of no longer carrying private insurance, but for those who want to keep their current insurance, it would be just a big tax increase.
You’ll need to make the case that Medicare is as good as your current insurance, and hence people can and should safely drop it. It’s a case that can be made, but it has to be made strongly. Otherwise the resistance to drop your current insurance will doom the effort.
Also, someone should run some preliminary numbers to see how much Medicare would increase per payer to cover the new beneficiaries. And because legacy beneficiaries are old and retired, and can’t absorb large premium increases, young beneficiaries would likely pay higher premiums that they would in a private scheme.
I still support Medicare Opt In, I support it very strongly, but a lot of details should be fleshed out
What this ignores is that Medicare and Medicaid both have inflated costs by virtue of the population groups they serve. Who knew that poor people and seniors had more expensive health care needs?? And poor people had even less ability to pay them? Well, everyone. As Medicare picked off younger, healthier patients to insure, the per capita costs would fall. The overwhelming share of health care spending comes in the last few years of life.
I've been trying to explain this to people for years.
You should check out El-Sayed's book, which gives a lot of the details of how a Medicare for All system could work. Also his podcast, and others that he's been guests on, have episodes that go into pretty heavy detail about how Medicare for All could work.
As for Buttigieg... there's a big problem I have with his plan, and others. An enormous chunk of the 2020 democratic presidential primary field (including Buttigieg) supported a public option over Medicare for All. As they dropped out, they coalesced around Biden, who also supported a public option and became its sort of standard-bearer. Biden, of course, won the election and then got into office, and then... proceeded to literally not mention his public option plan a single time his entire presidency. And I mean literally literally, not figuratively literally. During COVID, somehow he managed to completely ditch the issue, despite health coverage being at the top of many Americans' minds.
So there's a trust problem, right? How can I, as someone who really likes the idea of Medicare for All, but was willing to jump onto the public option train thinking "well, it's still much better than what we have", still believe that it's a serious proposal and not just a talking point used to crush progress towards Medicare for All? I don't trust that the bulk of more moderate candidates that pushed for a public option actually want a public option. I think they're more interested in keeping things as they are and making sure health industry checks keep flowing into the democratic party.
The democratic party moderates had their public option shot, they stymied Medicare for All for 4+ years for seemingly no reason at all, made absolutely no progress towards a public option (didn't even talk about it...), all while claiming that the public option was the better choice because it's the one that could actually get done. Meanwhile, progressives have continued pushing for Medicare for All in that time and now it arguably has much more support than it did. So tell me, which plan has supporters that actually believe in it and aren't just using it to get past democratic primaries? To me, the answer is clearly Medicare for All, and the trust of a public option is destroyed.
Why should Biden waste his time working on this while McConnell held the Senate?
You have to appreciate that there is a world of difference between "dedicating full effort towards something" and "not even mentioning something once". There's a lot of room between those two. Not mentioning it a single time is on the extreme end, akin to apathy.
One of the greatest strengths and roles of the presidency is to be a policy advocate to build support for what you want to see accomplished. Biden was entirely ineffective at this part.
Besides, how was the policy approached in the primary? Biden's public option was sold as *the alternative to Medicare for All that could actually get done*. You don't get it done by pretending it doesn't exist.
Then, look at his reelection campaign. Did you hear anything about the public option during his reelection campaign? I didn't. If there was any time to revive it, it would've been for his second term. Especially with how important of an issue it was within the base.
I simply cannot accept the argument that it was out of pragmatism. It's just bad politics, and bad politics is the antithesis to pragmatism.
2010 was heavily attributed to the economy. The ACA was very far down the causes, if it was even a cause. Very similar to 2024, really, where I believe economical concerns have to be the starting point for any analysis of why the elections went a certain way. Anything beyond that... show me the evidence. When there's a global wave of incumbent governments struggling, any country-specific reason is hard to believe. People like to attribute an election outcome to their reason of choice when most of them were fairly irrelevant. Heard it repeatedly from MAGA in the months following the 2024 election. "This is why democrats lost!" applied to the most benign reasons.
Also, it's 2026 and a new health system won't even be on the menu til 2029 at the earliest. It'll have been a long, long time since 2010.
It's 2nd, but it's 2nd by a mile, so I think "very far down" still applies. What is the makeup of the 18% that said health care was the priority to them? Given the near 50/50 split on those who wanted it overturned compared to those who didn't, might it be fair to assume that the makeup of that 18% is also similarly split?
Compare that to the economy with 62% of people saying it was their priority. I have a feeling that the makeup of that 62% was not so 50/50 in favor of the democratic side. Unfortunately, voters love blaming the current party in power for economic woes, right or wrong. Given the historic nature of the great recession, I think it's what drove the historic nature of the 2010 midterm.
There's also historical (and modern) precedent for how fallout from economic issues punishes incumbents. Look at what happened in the past few years from COVID economic troubles. The US was not alone in the incumbent party getting punished... it was like the 40th democracy in a row to have it happen. Similar to during the great recession recovery years.
Medicare A or B? The current Medicare payment out of your wages does not provide current coverage. A pays for hospitalization, but not physicians or drugs. You don't pay for private insurance "instead". You pay private insurance because you need or want it. Medicare paid while earning pays for Medicare post 65. Then when over 65, the Medicare wage tax you paid over the years and may continue paying as long as you work, requires no additional insurance payment. B is optional, no need to pay it if using private insurance. Same for Medicare D. Would Medicare for all mean hospitals free for everyone? Paid from a current tax? Or would premiums be charged, but hospitals compensated according to the Medicare schedule? Would a plan B be offered to everyone? Would B receive a generous general fund subsidy as it does now. If Medicare B were the only one required to accept all without a limit on pre-existing conditions it would be expected to cost more for each patient. But younger people generally cost less to cover. Would the optional B charge the about $1200/mo that B sees /patient with its ~75% subsidy? Would price be scaled by age? Would the ACA subsidies apply?
I agree. As an option - though probably foolish for a person not to take B and D or C, unless maybe religious objection to medical care..
A few additional thoughts. One of the biggest problems with today's system, such as it is, is the linkage of employment to health insurance. Ensuring that any transitional plan is directed at breaking this linkage is key. Second, a way to speed the transition to single payer is to build on something already in the ACA , mandating minimum medical loss ratios. If every two or so years, the minimum medical loss ratio was ratcheted up, eventually -- years, not decades -- health insurance companies would either get better or exit the business entirely. Finally, it's at least worth mentioning that some 600,000 people work in the health insurance industry. Their futures need to be taken into account.
Problem is that both Medicaid and Medicare depend heavily on MCOs - ie, insurance companies, many of whose "disgusting profits" are via their Medicaid/Medicare participation.
WE MUST MOVE PAST PATIENT BASED BILLING.
For example, the average emergency room visit costs $2,500 (with high variance). The cost of doctors + staff + operating costs + drugs + outside specialists per emergency room per year divided by number of patients served is $1,200. Medicaid and Medicare would save over $50 billion a year on ER costs if they simply paid each ER $1,200 times expected annual patient load (next year projections very accurate every year by every hospital) and bypass the MCOs entirely.
The Insurers would love it! They hate these villianizing, massively expensive hidden third party negotiations (and note that popular nonprofits BC/BS handle the Lion's share of health insurance).
Similar if Medicaid direct paid for EVERY PREGNANCY! Current is $25K billed per pregnancy ($30K total -6 mo to +6 mo) but actual direct cost is $6,000 per pregnancy. Directly paying for every pregnancy would save over $40 billion per year.
MEDICARE/MEDICAID DIRECT PAY ALREADY EXISTS (but is small).
SINGLE VOTE COULD MAKE IT HAPPEN. COULD BE REALITY BY THIS TIME NEXT YEAR.
Actually, would also need a vote to rescind ICE funding and restore safety net cuts in BBB - they approximately offset - and 80% of USA would approve.