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Is Big Change Coming? Jake and Kamala (& Michael and Howard)

Posted on | January 31, 2019 | No Comments

CNN’s Jake Tapper and Sen. Kamala Harris

Mike Magee

The decade long battle by Republicans to “repeal and replace” Obamacare is fading slowly into the background. But as this week’s dust up, ignited by CNN’s Jake Tapper’s probing of Presidential candidate Kamala Harris’s views on Medicare expansion revealed, we still have a long ways to go.

By the next morning, two of Harris’s potential opponents were selling fear at wholesale rates. Michael Bloomberg looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… (that) would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”

Remarkably neither man made the connection between large scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination.

Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability, suggesting Americans must instead accept the way health care is rather than having the courage to pursue how it should be.

Schultz is similarly short sighted. While acknowledging that the manmade opioid epidemic, mental health crises, and income inequality are “systemic problems” and at levels “the likes of which we have not had in a long time”, he failed to connect the cause (a remarkable dysfunctional and inequitable health care system) with these effects.

Today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature.  To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.

 “Universal health care” is an end point goal that reinforces the principle that health is a human right rather than a privilege for the most entitled.

“Single payer” is one strategy or tactic for efficiently delivering on the promise of universal coverage. It is often associated with the Canadian health care system. However, the Canadian system is not technically a “single payer” system, in that provision of insurance (set to national standards) and the delivery of the care are the responsibilities of individual provinces, not the national government. A more accurate label for their system would be “Single Oversight/Multi Plan”.

Canada has choice and also maintains a vibrant private health insurance market which covers supplemental health care plans purchased by 90% of citizens to cover roughly 30% of health costs including optical, dental and drugs which are not covered by government plans. Private insurers in the U.S. in the future might play a similar role.

Americans now in sizable majorities have embraced universal and mandated coverage, with choice. There is little need to force citizens with employer based coverage into public options like Medicare or extended Medicaid. Both employers and employees, given time and control, will support this migration on their own if allowed. 

The Canadian government’s role is focused on formalized government health planning as well as insurance standards and oversight. The national government also outlaws DTC drug advertising and sets prices annually for all essential drugs. The national government is the guardian of universality and (often overlooked) simplicity. Providers provide. Provincial government pays. Patients concentrate on health and wellness, and are not plagued by insurance gamesmanship and endless bill bickering on the local level.

On the most fundamental level, the U.S. has no such government-directed, national health planning apparatus. Service levels and reimbursement vary widely across an endless array of private and public offerings that have devolved into a “free-for-all.” What we do have are $4 trillion already committed  (albeit badly misallocated), a remarkable array of educational institutions, a dedicated network of public health schools and practitioners, an underutilized group of pharmacists anxious to contribute to their full potential, an expanding primary-care army bolstered by nurse practitioners and physician assistants, a testing ground of 50 different states offering the ability to customize various approaches to care within parameters set by the national government, a first-class and highly profitable scientific research and discovery community that could well stand on its own without diverting resources from health planning or patient care, and an enormous number of health system middlemen (16 positions for every one physician) currently involved in non-real work who need to be redirected toward strengthening services that would contribute positively to the social determinants of health—including improvements in nutrition, education, environment, housing, transportation, and safety.

Kamala Harris is right that simple justice demands universal health care for all of our citizens. But the winning argument at the end of the day for fundamentally revamping a broken system that consumes 1 in every 5 American dollars is economic.

The true impact of spiraling health care costs and their secondary effects—including stagnant wages, income inequality, a lack of job mobility, high rates of medical bankruptcy, the closure of rural hospitals, an inability to invest in infrastructure repairs, and our growing national debt – is staggering.

Warren Buffett, a man who knows something about sustainable growth, said recently: “The health care problem is the number-one problem of America and of American business. . . . Medical costs are the tapeworm of American economic competitiveness .”

Trump’s massive tax cut for the richest rich took us from bad to worse. On a percentage basis, the U.S. became the fifth highest debtor nation (as a percentage of GDP) in the world after Japan, Greece, Italy, and Portugal. Predictably, Paul Ryan then resurfaced the notion of cutting health services for the elderly, the poor, the marginalized and discriminated against – to “save Medicare” and address budget deficits that Trump and his allies had exacerbated through recent tax cuts for the wealthy.

For far too long, our leaders have focused on how to make American corporations wealthy. But let us be clear – there is another way. We could have the courage and the will to reapply our more than ample health care assets and reject the status quo. We could vote in change on a large scale.  We could elect leaders willing to honestly address a simple, long overdue question: “How do we make Americans healthy?”

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