Health care, in broad outline, is pretty simple. The free market, for obvious reasons, doesn't do universal. It sells stuff only to people who can pay for it. That’s why, for things like roads, national defense, the postal service, and old-age pensions—all of which we’ve decided ought to be available to everyone—we let the government do the job.
So if you want universal health care—or close to it—you have two options:
- Expand Medicaid or Medicare so everyone is covered. This is the simplest solution, but not all that popular.
- Keep private insurance but with changes. Obviously, if you want universal, that means private insurers have to accept anyone who wants coverage. They also have to charge reasonable prices even to those with expensive preexisting conditions, or else it's just a sham. But that means they'll lose money on those expensive patients, so they have to make up for it by charging more to healthy, low-risk customers. Poor people can't afford this, so the government has to subsidize them. And to make sure insurance companies don't game the system by selling stripped down plans, you have to mandate some level of minimum coverage.
There's no way around this. If you want to broaden access to health care, the requirements unfold with geometric logic. In wonkese, it means you need guaranteed issue, community rating, means-tested subsidies, and essential health benefits.
But conservatives don't like this stuff because (a) it costs money and (b) it requires a lot of government regulation. So they always end up ditching one or all of these requirements and retreating to their standard package: high-risk pools, HSAs, tax credits, interstate insurance sales, and “tort reform.” It's a mantra—and it wouldn't work. But who cares? Conservatives don't want to broaden health care in the first place, so it hardly matters if it works. They just want something that sounds plausible.
That explains why J.D. Vance said this on Meet the Press about Donald Trump's "concept of a plan" for health care:
He, of course, does have a plan for how to fix American health care, but a lot of it goes down, Kristen, to deregulating insurance markets, so that people can actually choose a plan that makes sense for them.”
....We want to make sure everybody is covered, but the best way to do that is to actually promote more choice in our health-care system and not have a one-size-fits all approach that puts a lot of the same people into the same insurance pools, into the same risk pools, that actually makes it harder for people to make the right choices for their families.
Regulating insurance markets is essential to health care reform. Putting everyone in the same risk pool is essential to health care reform. By placing them on the chopping block Vance is saying Trump doesn't want to make sure everyone is covered—but without actually saying it.
But make no mistake: that's what he's saying. Don't let a little bit of wonkese throw you.
sorry jd. all you've spouted was a concept of a plan. a lousy concept of a plan, just like the one john mccain shot down back in the day. now go back to your couch.
One of the easiest subjects to demagogue, because it's so complex, as Vance's comments indicate. Media types need to get smarter and push back and say "you're for less regulation, meaning you think not all people should have access to health care, since it's regulation that assures that." Only way to move forward on this is to call them out and educate the public.
Unfortunately, there just aren't that many general reporters with the knowledge and expertise to fully understand America's healthcare system, or environmental policies, or military weaponry, or even general economics, or, well, lots of other subjects. Which is why and how politicians can get away with Vance's response to Welker.
Yes I think you're right.
This is something the press will never do because the right will immediately accuse them of bias before they even finish the question. Instead of insisting on an answer they will give in and move on. This is Trumps greatest accomplishment (for his benefit of course). Neutering the MSM.
That neutering happened long ago. Trump's only contribution is to totally rip off its mask. I even had a brief ray of hope right after his election when they totally doubled down on "fake news" double speak. "Ha! People will see right through that." I let myself briefly think...
Unfortunately, the general population of the US has already been de-educated to the point that a frighteningly large majority of people are straight-up incapable of telling rank bullshit from obvious reality.
Of course they don't give a damn if every American has a chance to get decent health care coverage. So, of course, they'll trash the ACA if they get a chance.
As, of course, they'll trash Medicare by turning it all over to Medicare Advantage plans that provide less care and thereby make higher profits for the insurers.
I have seen many comments complaining about Medicare Advantage plans by people whose observations and reasoning I respect, so I don't dispute the perspective, but I have to conclude that MA plans must vary dramatically by location. I live in a very rural part of NY state and have a MA plan, and it has been spectacularly good. I pay $35/month -- the maximum, I'm not subsidized -- and it covers everything traditional Medicare covers, plus lots of extras including parts of dental and vision. Essentially everything and everyone around here is "in network" (so few doctors and hospitals, it would be hard to exclude anyone), and neither my wife (who has the same plan) nor I have ever been hassled about what is "medically necessary". In truth, I sometimes wonder how they make money (and fortunately so far, if they can't make money on me, it's hard to see how they could make it on anyone), but last time around they even lowered the premiums slightly.
I assume someone out there must have taken a good hard look at how MA plans differ in how well they serve the needs of the consumer?
You say you live in an area with “so few doctors and hospitals, it would be hard to exclude anyone,” which means you must live in a rural or small urbanized area. Once you get to urbanized areas with multiple hospitals, MA plans tend to get suckier: seniors have to go to a particular hospital or use particular doctors, to which they may not have adequate transportation (since seniors tend to also be the population that eventually loses its ability to drive). My aunts have MA plans and they increasingly bitch about how far they have to go to use those plans, or getting stuck with huge bills because the ambulance took them to the closest “wrong” hospital. (It’s really hard to convince an ambulance to take you to a specific hospital - they tend to want to dump you off asap so they can go out on their next assignment quickly, and you may be unconscious anyway and unable to pick a hospital).
That makes sense. As I said, my conclusion is that MA plans vary dramatically by geography.
FWIW, my employer has me on Kaiser, which functions like a HMO or MA plan - have to stay in network or they pay nothing - except that Kaiser also is the provider in all but emergency situations. I love it. But my metro area has like 20 Kaiser facilities, most of which are near frequent rail stations, so staying in network is easy… even though I have zero access to hundreds more doctors, medical centers and hospitals in my 5m person metro area. Choice isn’t always a good thing - it leads to stress at picking the “best” choice.
But another complaint my aunts had when they first went on MA plans was the inability to keep some doctors they had seen for 20+ years prior to turning 65. That’s a one-time cost of choosing an MA plan and generally it’s only important if you have something chronic for which you really liked your prior physician or specialist treating. But it is a cost to MA too: traditional Medicare doesn’t make you switch doctors when you sign up… and I imagine this cost falls more heavily on the already-sick vs healthy at age 65.
…” $35/month -- not subsidized -- it covers everything traditional Medicare covers, plus lots of extras including parts of dental and vision… In truth, I sometimes wonder how they (Medicare Advantage plans) make money”…
I don’t know exactly if/how profitable MA plans are for the insurance companies, but Medicare pays the MA plan about $12,000/year for each member, and if MA plan enrollees are generally better educated, healthier (less costly) than typical Medicare recipients, there could be selection effects, cherry-picking better risks from the overall pool… plus I read the USGov pays about $300/year more per MA plan member vs traditional Medicare member ($11,900 vs $11,600 a year)…
so for the insurance company, maybe less risk, maybe a little more money paid up front (not when claims are incurred), and perhaps most importantly, by agreeing to join the network, providers (dr.s and facilities) agree to an amount of control of “standard of care” through referrals and precerts and “allowable amounts” for consultations, procedures and services…
this control, by the insurance company, of their network-participating dr.s and facilities, is not typically that restrictive wrt costs and decision-making, mostly industry-standard stuff, but the control is there. (Typically Medicare is the most stingy with their payments to providers, but the most lax when it comes to directing and overseeing care. Payments are slightly smaller but easier to get. Medicare just pays everything, fraud becomes an issue occasionally).
More choices usually means no choice for those who can't afford it. They use the word choice to describe school vouchers too. They don't want expanded access to Healthcare for everyone just as much as they don't want access to good education for everyone.
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Yeah I love the “school choice” arguments. Not of much help in rural areas with only 1 high school, or urban areas without transportation to all but your local high school, or suburban areas where the “good” schools are already packed and aren’t taking new students (thank you very much), or private schools if they raise tuition higher than the voucher amount. But, three groups that school choice does benefit are (1) the upper middle class and rich who were going to pay for private tuition anyway, (2) the ultrareligious who hate their public schools for not allowing enough Jesus into the classroom and (3) the people who want public schools to go out of business completely either because they themselves want a piece of the education pie (eg the people who start up for profit schools) or because they want to indoctrinate kids into the Republican worldview (eg the people who hate schools for teaching history, science, equality, decency, etc.).
One other feature that is sometimes mentioned as necessary for universal coverage via private insurance = mandated insurance. That is, there should be a requirement that you must purchase some kind of health insurance rather than go without.
The logic behind this is that without a requirement that you must have insurance, many healthy young people will opt not to have any insurance at all. This in turn will shrink the pool of healthy subscribers whose premiums in any given year keep a health insurance company solvent. If too may healthy young people drop out of an insurance plan, then that insurance company will have to raise its premiums for those customers who remain. That increase in premiums, though, will cause further dropouts among healthy customers, which will lead to further premium hikes, more dropouts, more hikes, and so on in a "death spiral."
This was the rationale behind the provisions in the original Affordable Care Act tax that assigned tax penalties ($500 IIRC) that must be paid by people who opt not to have insurance, i.e. penalties. However, the Supreme Court performed a few legalistic somersaults and struck those tax penalties down as unconstitutional. So, now there are no federal tax penalties for being uninsured.
I recall in the wake of the court's decision worrying about "death spirals" materializing and proving over time to be a mortal threat to Obamacare. Apparently not. Obamacare is still here. (Though perhaps its premiums are more expensive now than they would've been had the tax penalties remained in place; who knows.) I guess that even the young and healthy are rational enough to see that it's foolish to go without health insurance, so that there is sufficient participation levels from them to sustain private insurance. Whew.
tl;dr: Pre-ACA discussions of "what is necessary for universal private insurance to work" typically also included a mandate requiring everyone to purchase health insurance. Fortunately, Obamacare has proven able to survive without such a mandate.
cdunc123 - I too recall this discussion. The reason, I think, that the ACA still works without the penalty is most people, its about 80%, are getting free or significantly subsidized health care.
I suspect, if you required purchase of health insurance, without subsidy, the ACA enrollment would drop materially/ you would have the so called, death spiral.
https://www.kff.org/private-insurance/issue-brief/as-aca-marketplace-enrollment-reaches-record-high-fewer-are-buying-individual-market-coverage-elsewhere/#:~:text=Almost%204%20In%205%20Individual%20Market%20Enrollees%20are%20Subsidized&text=Heading%20into%202024%20open%20enrollment,and%20short%2Dterm%20plans).
middeloftheroaddem -- Good point. If subsidies are a big enough "carrot," then maybe no "stick" (tax penalties) is needed, after all, to get enough healthy people into the coverage pool. (Thanks too for the think.)
Premiums are about equal to US medical spending divided by population...
...but they're still more than say, a year at the highest state minimum wage. Which makes them difficult to pay for.
"However, the Supreme Court performed a few legalistic somersaults and struck those tax penalties down as unconstitutional." Not true. The Court, led by Roberts, declared the mandate a tax penalty and therefore Constitutional (just barely). Subsequently Congress passed a law reducing the penalty to zero, effectively eliminating it.
That led to an attempt to declare the ACA unconstitutional on the basis of some incredibly twisted logic that amazingly made it all the way up to SCOTUS before being dismissed.
In any case, Obamacare survived.
Batchman -- You're right. My memory was faulty. As you say, it was Congress, not the court, that undid the tax penalty. My anxiety followed that law change, not the court's decision. I should have doublechecked my facts before posting. Thank you for the correction.
cdunc123, what the hell are you doing?? This is the internet, you don't just say "you're right, I was wrong". And "thank you for the correction?". WTF!
Geez...computers are dangerous in the Wrong Hands.
/s
It also works because, even though the penalty has been eliminated, you can’t just sign up for health insurance whenever you want (eg as soon as you find out you have cancer or get into a car accident). Signups are once a year in non-emergency pandemic years, and pre existing conditions are still banned for a number of months after sign up if you had no insurance before, so you have to really feel invincible to forgo coverage.
I think, in the end, the biggest GOP challenge around health care is how to finance a broad program.
- In Europe, Japan, Canada the rest of the OECD, they draw a lot of money from a VAT (value added tax); this is a broad based tax, paid by everyone.
- In the US, given our politics any healthcare expansion, likely means a tax just/or primary on corporations and the very wealthy. Significantly redistributive.
The Dems don't support a VAT tax and the GOP will not support broad redistribution...
I'm European and not aware of VAT largely financing health care. I lived in Holland which has mandatory private insurance regulated by the state. In France I always paid social premiums for health insurance. Both systems are regressive: private insurance because low earners pay a higher percentage of their income than high earners, social premiums because they max out at a certain income. But the regressiveness doesn't bother people because (a) insurances are almost always regressive and (b) they don't come close to costing as much as in the US.
ruralhobo - a quick google search. Netherlands VAT is 21% on most goods and services (clearly I just simplified things a bit). VAT revenue in the Netherlands, is about 33% of the government's total revenue. For the Dutch government, ballpark, VAT revenue is equal to personal and corporate taxes combined.
So you are, in a sense, right: the VAT pays for national health care in the Netherlands and many other things.
https://www.oecd.org/content/dam/oecd/en/topics/policy-sub-issues/global-tax-revenues/revenue-statistics-netherlands.pdf
Risk pools, aka, insurance that goes up when you're injured or sick.
So how is it insurance?
It's not. They know this. But they also know people will fixate on the word choice and ignore virtually everything else.
Just like most insurance. For example, typically your car insurance goes up in price, after an accident...
Conservatives like nothing better than hearing about somebody else who died.
It might be a distinction with not much of a difference, but I think
they like hearing they didn't have to spend money keeping someone alive. It's the callousness and complete lack of sympathy that drives their actions. To them the life lost is irrelevant to the money spent.
One less rival to steal their onions, chickens and women.
The electorate is simply not super informed. The US is one of the two large "isolated" first world economies, with China as the other and India due to be the third.
When you are isolated, pointing out what works in Europe, which is simple enough for the dumbest European, is a bridge too far for at least 70% of Americans.
That's all, folks. Until there is a broad based acknowledgement that capitalism is not the be all end all we are going to be stuck with some very expensive structural mistakes in this country. Health care being one of them, but perhaps the most obvious one.
P.S., look at Trump's latest name for Harris "Comrade" -- he's not picking that one because 70 million of his followers thinks its stupid - hes picking it because its a great insult. Or at least a great insult in the US.
This is a good point. Its surprising how many Americans are completely unaware of how many other countries have figured out the health care thing. Affordable, easy to access, high quality results.
You've overlooked that deregulating markets fixes everything. Republicans told me so. If it doesn't fix YOUR condition, you're just not the deserving poor.
Do they consider any of the poor deserving?
Because I can't help myself after reading this exchange, here's the eminent philosopher Alfred P. Doolittle (with a tip of a wedding day top hat to Stanley Holloway):
"What am I? I ask you, what am I? I'm one of the underserving poor, that's what I am. Now, think what that means to a man. It means he's up against middle-class morality for all the time. If there's anything going, and I puts in for a bit of it, it's always the same story: you're undeserving, so you can't have it. But, my needs is as great as the most deserving widows that ever got money out of six different charities in one week for the death of the same husband. Heh, I don't need LESS than a deserving man, I need MORE. I don't eat less hearty than he does, and I drink... oh, a lot more. I'm playing straight with you. I ain't pretending to be deserving... no... I'm undeserving, and I mean to go on being undeserving. I like it, and that's the truth."
"But conservatives don't like this stuff because (a) it costs money"
Cut the military budget 5% per year for 10 years. That'll fix all our money problems.
The GOP regularly has politicians who want to stop covering pregnancy and birth because they aren't "diseases." These people really don't care at all how many people suffer and die, as long as it lets the rich get a little bit richer.
If you are male you might not want to pay for maternity care/gyn stuff, if single, and if you are female you probably dont want to pay for prostate care but beyond that what exactly wold you want your insurance to not cover?
Steve
There's nothing wonky about what Vance said.
"choice" is "freedom"
Vance is expressing the conservative's dogma of "give me freedom or give me death".
The Vance inference is that death is better than losing your right of choice. It doesn't take but one journalist to ask him the question, "Are you inferring that death is better than losing your right to choose?"
LOL! Vance doesn't want freedom when it comes to reproductive choice. What Vance wants is the freedom to choose what your choices are.
Some choices are verboten, based on the conservative patriarchy, naturally.
[Trying this again.]
Didn't we just spend the better part of a decade fighting this battle? Can't we ever settle an issue and leave it alone? The defining trait of conservatives, and especially Trumpists, is to never let the past be past and always to question anything that has the slightest scent of progress.
Our public discourse is filled with debates about issues that are long past the point of being debatable, and in many cases were never debatable in the first place. Should women have the right to choose what to do with their own bodies? Is climate change really a threat to civilization? Are Nazis the bad guys and the good guys won WWII, or was the whole mess Churchill's fault? Wasn't life much better before we began this experiment with democracy? Isn't one Black president enough for anybody's lifetime and why do we have to do it again?
Some of those are not spoken aloud (though Donald and JD, given the chance, will get around to it). They are the subtext of a lot of what seems to be "up for debate" these days.
One issue may be there is just too much time and space for news and not enough real news to report. Even non-ideological debates are things that are not debatable. Will the Fed cut rates a quarter point or a half? Should Aaron Judge win the AL MVP or Bobby Witt Jr.? Did Rich Lowry really call Haitians the n-word on the Megyn Kelly Show or do you not believe your own ears? Countless hours are spent on "debates" that anyone with a working brain already knows the answer to.
But media needs conflict, and there's not enough real news to keep everyone's attention, so in their desperation to keep the attention of the bored and apathetic public, they "create stories" (just like JD) to get us fighting about something again. (What's that, JD? Deregulate the health insurance market? Well, that's an idea, isn't it? Let's feed it into our algorithm and see how it plays.)
P.S. There is some real news. Hundreds of pagers belonging to Hezbollah exploding at the same time. Haven't seen that before. But if "the news" was only about what's new, it would be over in 15 minutes, like it used to be. Can't have that with 24 hours in a day.
P.P.S. The ultimate non-debatable debate is Donald Trump. The scummiest specimen of human life in the history of this country, or a man qualified to be president of the United States? No sane person would spend two seconds answering that question, but the media has sold a lot of airtime and newspapers (not to mention, their souls) keeping the "debate" alive for more than 8 years.
"Donald Trump doesn’t want to broaden health care coverage"
The idea that Trump care about health care, one way or another, is just stupid. He may have enough grudge against Obama to repeal Obacamacare just for the hack of it, but otherwise he doesn't care about this at all. The same applies to Vance.
This is all campaign propaganda, irrelevant to what Trump will do if he wins. But treating it as if it is a good faith presentation of their intentions you are helping them to bamboozle the public.
Yeah, Donald Trump couldn't explain what that sentence means, let alone make a cogent assessment of how one policy or another might affect such a quality.
Donald Trump doesn’t want to broaden health care coverage
it's pretty clear that if a kid was on fire trump wouldn't bother to piss on them to put it out
trump has never helped anyone but trump; he's a sociopath
There is no doubt about how to provide universal healthcare at lower cost, because almost all other countries do it. The solutions have variable degrees of state vs private provision, but they all involve more regulation, not less. This is not a theoretical problem.
The media are supposed to provide facts to the public, and the most important fact about health care is how the US has incomplete coverage at about twice the cost of other countries. But what they do instead of presenting the facts is repeat the nonsense of Republicans about how the "free market" is always the solution.
I suppose Democratic politicians don't talk about how the foreign systems are far superior because they are afraid of seeming unpatriotic, but the media are not running for office. I suppose the media are afraid of losing advertising revenue if they don't do bothsiderism.
Il Duce has been talking about repealing and replacing the ACA (simply because its Obama's signature legislation) since at lease 2015. He said his plan would cost less, be much better, and would be so easy to do.
Its 9 years later and he still only has bull shit to talk about. He had a party at the WH after the House passed the repeal of the ACA, and was of course only 1 vote away from it passing in the Senate (John McCain's famous thumbs down). There was only a repel of the ACA, no replacement in sight.
Again, the US electorate must be total morons to believe any of his BS again, after he came within a whisker of repealing the ACA.
I've seen journalists interview people who rail against the evil socialist Obamacare, only to be told that their insurance, is, in fact, Obamacare, and watch them just stare in disbelief and then assert they don't care, their insurance is fine, but Obamacare sucks anyway.
It's tough to run a democracy when so many voters are so very, very ignorant about virtually everything. Except guns and cars. Lots of experts on those things.
"But conservatives don't like this stuff because (a) it costs money and (b) it requires a lot of government regulation. "
That's not why. Medicare negotiating drug prices costs less and does not require regulation, it's a free market policy. And republicans have opposed it for decades. You know better than to buy into their lies, Kevin. They are evil assholes driven by greed, anger, racism and every other terrible aspect of human psychology i can think of.
When a Republican these days talks about "health care choice" or "more options," it's just code for shitty, faith-based grift operations that take people's money, but have all kinds of exclusions and often fail to pay out even on the stuff they say they will cover.
Trump doesn't understand the last damn thing about health care policy. Vance is smart enough to know better, which is why he's doubling down on the weasel words here.
But conservatives don't like this stuff because (a) it costs money and (b) it requires a lot of government regulation.
No, conservatives don't like this stuff because they believe people don't deserve it. They're convinced people don't have health coverage because they're lazy. If people aren't wealthy, it's because they're lazy. Unlike the hardworking, virtuous wealthy people who got their fortune the old-fashioned way: they inherited it.
I don't think Vance understands how insurance works.
Or maybe he does. He's already admitted that he doesn't mind lying to attract media attention.
BTW, Trump has had at least a decade to think about this and all he has are "concepts?"
Democrats have policies. Republicans have cover stories.