Thursday, July 9, 2015

qotd: Seidman and Pollack: ACA versus Medicare for All

Journal of Health Politics, Policy and Law
August 2015

The Affordable Care Act versus Medicare for All
By Laurence Seidman


Many problems facing the Affordable Care Act would disappear if the
nation were instead implementing Medicare for All — the extension of
Medicare to every age-group. Every American would be automatically
covered for life. Premiums would be replaced with a set of Medicare
taxes. There would be no patient cost sharing. Individuals would have
free choice of doctors. Medicare's single-payer bargaining power would
slow price increases and reduce medical cost as a percentage of gross
domestic product (GDP). Taxes as a percentage of GDP would rise from
below average to average for economically advanced nations. Medicare for
All would be phased in by age.

Medicare for All — If It Were Politically Possible — Would Necessarily
Replicate the Defects of Our Current System
By Harold Pollack


Medicare for All, ideally implemented, could offer powerful advantages
over our current health care financial system. Unfortunately, the
political obstacles to such a system are formidable and are likely to
remain so for decades. More to the point, a politically viable
single-payer system would not replace our currently dysfunctional health
care politics. It would be a product of that same legislative process
and political economy and thus be disfigured by the same interest group
politics, path dependence, and fragmentation that Laurence Seidman
rightly laments.

From the text

Laurence Seidman's brief for single payer will be congenial to many
JHPPL readers, and for good reasons. As someone who has spent the past
seven years advocating for the Affordable Care Act (ACA), I must concede
that a well-conceived, well-implemented Medicare for All system would
offer powerful advantages over our current health care financing system.

Medicare for All would be fundamentally more disruptive for tens of
millions of people. As a matter of basic accounting, a huge reform that
creates millions of winners creates millions of losers, too: affluent
workers receiving generous tax expenditures, too many constituencies to
count across the supply side of the medical economy who are likely to be
squeezed in a new system, individuals subject to small or large tax
increases, to name a few. This list includes some of the most powerful
and organized constituencies in American politics. They would have to be
accommodated in complex, sometimes unappetizing, ways.

Medicare for All cannot offer itself as the replacement of our
depressing health politics. It would have to arise as another product of
that very same process, passing through the very same legislative choke
points, constrained by the very same path dependencies that bedevil the ACA.

For the foreseeable future, the main health policy challenge is to make
the ACA work.

I hope that the public option returns in some form as a viable choice
within the new marketplaces. One possibility would be to allow
individuals over the age of sixty the option of purchasing public
insurance coverage. Many Americans would welcome this option, which
would also provide needed competition and market discipline of providers.

Policies like this may someday pave the way to a Medicare for All
system. More likely, these would allow the possibility of public
insurance carving out a complicated coexistence with private coverage.
This may be the best outcome. If we keep our shoulder to the wheel in
pursuing the messy, frustratingly incremental process of health reform,
we can create a more humane and disciplined health system. That's no
small accomplishment. I'm not sure what else we can do either.


The New Republic
August 2009
Will Doctors Be An Impediment To Reform?
By Harold Pollack

On the left, there are Physicians for a National Health Care Program. (I
happen to dislike PNHP leaders' unhelpful stance in the current debate,
but that is another story.)


The Incidental Economist
December 3, 2011
How not to argue about health policy
By Harold Pollack

One can make a principled decision to withdraw from the incremental
politics of American health policy. I understand why single-payer
advocates are tempted to take this course. Most do so with greater
awareness of the attendant tensions and costs. PNHP was a sideline, not
always very civil participant in the political fight to enact and
preserve health care reform. Indeed its leaders denigrate important
provisions of ACA that expand access for 32 million people and protect
millions against catastrophic financial risks. I wish the group would
talk and act rather differently in this debate.


Comment by Don McCanne

This pair of Point-Counterpoint articles from the Journal of Health
Politics, Policy and Law renew the debate over the Affordable Care Act
versus Medicare for All. Laurence Seidman presents the solid case for
the policy superiority of the single payer Medicare for All model while
Harold Pollack also acknowledges the superior policies of single payer,
yet rejects it based on our dysfunctional health care politics.

Policy is not the issue in this particular debate; it is the politics.
You do not compromise clearly superior policy to conform with the
dysfunctional politics, but rather you change the politics in order to
support optimal policy.

PNHP's mission is to educate the public on the single payer model - an
essential step in changing the politics. Harold Pollack instead supports
incremental changes, such as those of ACA, as a means of negotiating the
politics. Both approaches are reasonable and neither should be
completely rejected in deference to the other one. The ultimate goal
should always be the utopian version of single payer, and every effort
must be made to achieve that goal. In the interim, incremental measures
that improve health care should be supported. But it is important to
continue to inform the public on the inadequacies of these interim
measures that perpetuate hardship and suffering, lest inertia set in.

Harold Pollack writes about "pursuing the messy, frustratingly
incremental process of health reform," and says, "I'm not sure what else
we can do." Yet he concedes that "a well-conceived, well-implemented
Medicare for All system would offer powerful advantages over our current
health care financing system." He says that he wishes PNHP "would talk
and act rather differently in this debate." This defies any
interpretation other than that PNHP should abandon their mission of
single payer and join him in supporting his incremental pathway to
reform. Yet he suggests that "the best outcome" may be "the possibility
of public insurance carving out a complicated coexistence with private
coverage." PNHP emphatically disagrees that this would be the best outcome.

Recognizing that policy goals must not be compromised and that the
politics must change, we wish the incrementalists "would talk and act
rather differently in this debate." After all, we do share the ultimate
goal of health care justice for all.

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