The David & Goliath Fight for Medicare for All
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Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
How was the Affordable Care Act hampered in recent years? How did the COVID pandemic further exacerbate access to health care? Jim Kahn, an emeritus professor of health policy at the University of California San Francisco, gives us his take on these issues and more. He has served as a consultant to the World Health Organization and the World Bank.
Q: So you’re an expert in health economics and global health. Tell us what convinced you that single-payer is the healthcare reform that we need?
Kahn: Of course, I have known people my whole life who have had trouble getting care but I didn’t really gel my ideas about healthcare reform until about 1994 when the state had a ballot initiative on single payer called Prop. 186 and at that point I started to look more seriously at the various ways to reform health care, and was very interested in this idea of a single payer. It made a lot of sense. It seemed to remove the profit motive from paying for health care. It seemed to simplify things for doctors and patients. Subsequently, I’ve been very interested in how other countries, other wealthy democracies, deal with health care and while they don’t all have single payer, many of them do and the ones that don’t have the key features of single payer, like everyone has the same health benefits — full stop. Exactly the same. None of this slightly different this or that, no marketing around what’s in the benefits package. It’s so much more reasonable and so much more efficient and leads to better outcomes.
Q: Thank you for that. So we’ve spent the last year grappling with the coronavirus pandemic. How has this crisis illustrated the need for healthcare reform beyond that that’s provided by the Affordable Care Act?
Kahn: Well, first I’ll say that the Affordable Care Act, while it certainly has its limitations, did improve our situation for health care in the United States and many of those improvements were reversed by the Trump administration. Although they couldn’t undo the Act entirely, they were able to cripple it in certain ways. So we came into the COVID pandemic with an already re-injured healthcare system, if I can say that. And as it was limping along, along came COVID and what we realized is that, first of all the people who needed the protection of stable health insurance often lost it because they lost their jobs. And as everyone knows, in the United States, health insurance is often linked to employment. So when people were laid off because companies had to close because of COVID, they were out of luck with regards to their insurance.
The second issue is that some of the COVID-specific benefits that were promised such as care without cost-sharing for COVID and free testing, it turned out in practice those things didn’t always happen. For example, someone with diabetes, or congestive heart failure came in and had COVID and a determination was made that the reason they were sick wasn’t due to the COVID, it was due to their other condition and so that didn’t always work out and then to add insult to injury, the profit margins for insurance companies this past year during the pandemic work were extraordinarily high — twice as high as in prior years.
Why is that? That’s because people were staying home. They were postponing elective procedures. They were making tough decisions not to go to the doctor so quickly when they got sick because they were afraid of getting COVID by going to the doctor. So, healthcare utilization did go up for COVID but it went down even further for other medical conditions. There was less medical care to be paid for and who benefited ultimately, the shareholders of the for-profit insurance companies.
Egregious is the word that comes to mind when I think about profiting on the backs of people who had suffered from a loss of health care as a result of COVID.
Q: You also mentioned that the Affordable Care Act was reversed in some ways under the Trump administration. Do you want to just name one or two key ways that that Affordable Care Act was — parts of it — were reversed?
Kahn: Sure, the individual mandate — that is a requirement for people to get insurance or else pay a tax penalty — was undone as part of the 2017 tax law. The punishment part of that was removed.
The other big thing that was done is that the Trump administration took a feature of the ACA intended to help people when they were quickly changing between jobs — a temporary insurance that was allowable up to 30 days to bridge between jobs but had none of the requirements of the health insurance purchased year long on the exchange. Requirements like community rating of premiums, and all the other good protections for people with insurance. Those were not required of these short-term policies, which under Obama and the ACA were defined as lasting up to 30 days.
So the Trump Administration couldn’t reverse that but they could redefine what constitutes temporary and what did they come up with as temporary? Up to 364 days. So now, people can be encouraged to buy policies that are essentially a year long, just a day shy of a year, but those policies no longer have the protections that a full proper ACA plan would have…all of those very important protections — undermined by reclassifying plans to 364 days as temporary.
Q: Oh wow, that’s good to know. Thank you. It seems like the California Legislature has been toying with single payer legislation for a couple of decades and yet the state never seems to get there. Why do you think that is?
Kahn: The insurance companies and other big financial actors in our health system are powerful. Remember, health care constitutes almost 1/5 of our entire economy, and about half of that is through private insurance companies who make a lot of money. In addition, some hospitals currently are making out extremely well. They have market power. They’re able to raise prices, particularly what they get paid from the private insurers. So they’re making out extremely well. Their executives are getting paid massive amounts and if they’re for-profit their shareholders are benefiting hugely as well, the drug companies, too of course. These guys are aligned against single payer.
What’s amazing to me is that despite all of these vested interests and their ongoing efforts to portray the health system problems in a way that suggests that single payer won’t help, they’re trying to bad mouth single payer, despite that, about 60% to 70% of the population if asked in a neutral way, support the idea of the government paying for healthcare. In other words, to answer your question slightly differently, it’s not surprising that it’s been difficult. What’s amazing and encouraging is that support for single payer is high and continues to grow.
Thank you, Jim Kahn.
Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.
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