Health Care/Joan Retsinas

Incremental: The Verboten Word

Ask a progressive for the taboo word in health policy: incremental. nnThe phrase-du-jour is Medicare-for-All. We need it Now. All the Democratic candidates for President take the litmus test: are they “for” Medicare for All? Or have they sold their souls to the insurance companies? Candidates who waffle on this test risk spurning the progressive bloc.

Let’s drop the slogans. Progressives, as well as many people who would not label themselves anything, want universal coverage for a comprehensive package of benefits. They want to end the pre-existing exclusion clauses, the “not covered” stipulations, the gobbledygook of the limited networks. They want insurance that they can pay for without sacrificing rent or food. Only our President and his ideological cronies would object.

But the route from here to there is, frankly, incremental.

Consider Medicare itself. It did not spring forth de novo, but grew out of the Blue Cross/Blue Shield model. Medicare Part A corresponded to Blue Cross’s hospital insurance; Part B, to Blue Shield’s provider insurance. Medicare extended that coverage to people out of the workforce (retirees and the disabled). While Uncle Sam oversaw Medicare, Uncle Sam contracted with insurers like Blue Cross and Blue Shield to manage it, as “fiscal intermediaries.” Medicare was astounding legislation in a country that feared the footprint of Uncle Sam; indeed, a host of organizations, including the American Medical Association, predicted catastrophe if Congress passed Medicare. But from a long-term perspective, Medicare was incremental.

Its benefits package also grew, incrementally. Congress added kidney dialysis in 1972; Congress authorized prescription coverage, Part D, tied to private insurers, in 2003. In the early 1970s, Medicare introduced Advantage Plans in selected markets, modeled after the capitated HMOs. In 1997 Congress authorized the plans, Part C. Rhetoric aside, the basic Medicare package does not cover eyeglasses, hearing aids, dental care, or long-term care.

Fast forward to the Affordable Care Act, aka Obamacare, another incremental step, aimed at the uninsured. At that time, Congress rejected any extension of Medicare, via the “public option.” Uninsured citizens could buy insurance, with subsidies, from private companies via the exchanges. And, crucially, Congress curbed the worst abuses of private insurers, like the pre-existing condition exclusions, the limited benefits. (President Trump has blessed “skinny” plans, returning to the pre-Obamacare misery).

Fast forward to today. The rhetoric screams: Medicare for All, a phrase that frightens enough voters to doom a Democrat.

The reality is that we can move towards that end without threatening the enrollees in private plans who profess to like their insurance, at least until they face a medical catastrophe, a soaring premium, or a mega-deductible.

Let Uncle Sam take over Medicaid, extending its reach to people whom states could have covered under the Affordable Care Act, but chose not to. The Kaiser Foundation pegs the number at 14 million. Uncle Sam can take this out of states’ hampers, out of states’ budgets. (Food stamps also comes under Uncle Sam’s purview). Include the States’ Children Health Insurance Programs (SCHIP). It is hard to imagine states, which complain about the costs of Medicaid, complain that they want to keep it. Call it Medi-Kid.

Put the public option into the marketplace. Let uninsured buyers consider Medicare among their choices on the exchanges. (President George Bush the first had proposed letting people buy into the health insurance plans open to federal employees — a proposal that preceded the spirit of President Obama’s exchanges, but went nowhere. President Clinton had proposed letting early retirees buy into Medicare — it too went nowhere).

Let corporations give their employees Medicare as a choice, not a mandate.

Lobbyists are already objecting: a public option would take away the incentive for private insurers to stay in the exchanges, would weaken hospitals that net less from Medicare than from private insurers. “The sky will fall,” to quote Chicken Little.

But “government” already covers a swatch of Americans, either through Medicare (17.2%), Medicaid (19.3%), or the military (4.7%). Throughout all the incremental steps, the sky did not fall, and the private sector stayed solvent.

Ultimately, drop the nifty litmus test. We must elect a president who can move this needle.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, September 1, 2019

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