Hey, Bernie, Make It a Real Single Payer Bill…No Profits

Senator Bernie Sanders has announced that he is going to introduce his Medicare for All bill in the Senate—and hold a hearing.  This is most welcome news.

As Bernie campaigned for the presidency, he elevated national single payer health care, an improved Medicare for All, into the public spotlight and onto the nation’s agenda.

His advocacy for Medicare for All informed millions and lifted spirits building hope that a universal single payer plan is possible in the US.

He has not done that well at writing legislation.  His most recent bill, the Medicare for All Act of 2019 (S. 1129), falls short of essential single payer principles and lets stand billions in profits that will undermine care and steal public funds.

With a majority of people in the U. S. now delaying care because of cost and life expectancy sinking to 5 years below other wealthy countries, the crisis is too great and the life or death urgency too immediate for half measures.

Here are the issues in Sanders’ 2019 Medicare for All Act (S. 1129) that need to be resolved prior to introduction of Medicare for All in 2022.

1. S. 1129 leaves institutional long term care to the states under Medicaid instead of including it in the national Medicare for All program. Leaving long term care to the states means that it will continue to be means-tested, and people will have to become impoverished to be eligible. The rules and care will vary from state to state leaving the fragile elderly and disabled persons dependent on state budgets that are continually being cut.

2. S. 1129 allows the investor-owned hospitals, nursing homes, dialysis centers—all the for-profit facilities–to continue to exploit patients and drain the public treasury. Objective research consistently shows that investor-owned entities have both lower quality care and higher costs.  That’s why a sound single payer bill must convert those facilities and ban for-profit health care institutions, ending the waste of public funds on facilities that subject patients to inferior care.

3. S. 1129 does not provide for global budgeting, lump sum payment to hospitals and similar institutions to cover operating expenses, that would eliminate wasteful per-patient billing. Global budgeting, separating operating budgets from construction, expansion, and modernization, is essential to assure that funds are not wasted.  Separate capital budgets will guarantee that facilities are built where they are needed.

4. S. 1129, in section 611(b), adopts the payment systems of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Affordable Care Act (ACA), basing payments on an unworkable, unfair, and wasteful system supposedly rated according to value. Such payment schemes have proven to discriminate against those physicians who serve the poorest patients and minority communities while adding massively to the administrative tasks and burn out of physicians.  These alternative payment models (APM) or value-based payments (VBP) in S. 1129 embed risk and profit into the payment system and should be banned.  They impose schemes that incentivize denial of care to enhance profit.  These payment systems are the basis of the current privatization of Medicare through the direct contracting entities (DCE) program, recently renamed ACO REACH.

5. While S. 1129 removed most copays and deductibles, it keeps a copayment on certain drugs.Copayments have been proven to deprive patients of necessary care and are detrimental to health.

6. S. 1129 inserts supposedly incremental steps of public options and Medicare buy-ins for four years prior to arriving at a real single payer plan. Because the plan expands care while maintaining the private insurance companies, costs will skyrocket before the savings of single payer kick in. The incremental steps will become a roadblock rather than a path to single payer.  Perhaps the worst part of this inclusion of the public option and the Medicare buy-in is the reinforcement of the false notion that there should or must be incremental steps to single payer.  Neither the public option nor the Medicare buy-in are based on sound policy.  To place them in the bill endangers the single payer goal.

7. S. 1129 is silent on the establishment of a progressive taxing mechanism that would shift the tax burden from working class Americans onto the corporate elite and the billionaires.

8. While S. 1129 provides for up to 1% of the budget to be used for temporary worker assistance programs for those who experience economic dislocation as a result of implementation of Medicare for All, there is no specific annual compensation for a specific period that could win the support of workers in the insurance industry.

Ricky Goldwasser, managing director at Morgan Stanley just announced that there will be even more consolidation in the healthcare industry in the coming year with more Wall Street mergers and acquisitions and more takeovers of physician practices by private equity.  Some highly-respected health policy experts are now asserting that Medicare for All is not enough and that the nation must move to a national health service to escape control by the profit-takers.  The introduction of health care legislation reflecting that opinion would also be welcome.

The very least that Congress can do is propose a real single payer bill, stripped of the profits, and covering us all.