Bro-Ha-Ha: How *I'd* get to Universal, Comprehensive, Affordable Coverage (PART I)

UPDATE 2/05/16: Unfortunately, I got swamped this week with the actual enrollment wrap-up stuff and never got a chance to write up the Part II promised at the end of this. I might have to re-think how I do this. I'll leave this post online, but might ot be referencing back to it for awhile longer than I expected. Sorry about that.

A couple of weeks ago, I made a YUUUGE mistake: I dipped my toe into the Hillary/Bernie/Single Payer fuss. Actually, the mistake wasn't so much my post, but cross-posting it over at Daily Kos, where it caused a bit of a fuss, which in turn led to my getting embroiled in the so-called "Bernie Bros Brouhaha" (Bro-Ha-Ha?), and so on.

Christ, it even turned into a bit of an M.C. Escher drawing, with Glenn Greenwald using the personal attacks on me by Bernie supporters to defend Bernie supporters, while Parker Molloy went from (indirectly) defending me (and other victims of "Bernie Bro" attacks) to actually accusing me of "Bernie Bro" behavior myself...because I made the mistake of responding to her Medium story via Twitter before I had actually read the entire story. (Note: I immediately realized my error and apologized, but she has yet to respond).

Better yet: This, in turn, led to another hostile encounter with another extreme Bernie supporter...a female one in this case, who was off her rocker, which in turn kind of proved Molloy's point about "Bro" not neccessarily having to be male. Additional irony: In both cases, I had actually been attempting to defend, or at least smooth over, the "Bernie Bro" insanity. And so it goes.

In any event, I had made a couple of other mistakes in my original post: While the title of the piece mentioned "siding with Hillary on healthcare", the post itself was really more about a) the problems I have with Bernie's plan and b) my own idea about how to eventually get to a single payer system...not what Hillary's plans actually are. In response, the following day I posted another piece which looked into what Hillary Clinton's ideas on healthcare policy actually are. On the one hand, they're far more detailed than Bernie's, which is a very good thing. On the other hand, even if every one of them were to be fully implemented, they'd significantly improve the current system but no, they still wouldn't bring about either single payer or universal coverage by themselves.

The thing is, until about a few days ago, I was operating on the assumption that Hillary was, indeed, dedicated to achieving some form of Universal Coverage...which is NOT the same as Single Payer. Single Payer refers to how healthcare is paid for for those who are covered; Universal Coverage is about how many are covered. After all, Medicare is Single Payer and Affordable...but it's neither Universal nor Comprehensive. Bernie's ideal is all four: Comprehensive, Universal, Affordable and Single Payer...but you can achieve the first three without necessarily requiring the fourth, as numerous other nations have proven.

Just a week or so ago, Clinton stated, during the CNN Town Hall:

So, I know in order to deal with the problems I want to, to get the economy working, creating more good jobs, getting incomes rising, making sure we build on the Affordable Care Act. Get costs down, but improve it, get to 100% coverage.

Note that Universal Coverage (100%!) is mentioned...but is mentioned 5th, after "the economy", "more jobs", "higher incomes" and "improve the ACA" (which isn't the same thing, of course).

HOWEVER, a few days later at an Iowa campaign rally, she kind of stepped in it with this:

"I want you to understand why I am fighting so hard for the Affordable Care Act. I don't want it repealed. I don't want us to be thrown back into a terrible, terrible national debate," Clinton said as Hanna took the stage. "I don't want us to end up in gridlock. People can't wait. People who have health emergencies can't wait for us to have a theoretical debate about some better idea that will never, ever come to pass."

Needless to say, this set off warning bells with me, so I posted a piece noting that while Bernie seems to be promising too much, too quickly...Hillary seems to not be promising enough...ever. I want clarification about just what she has in mind, not just short-term, but what her vision is long-term (even if a lot of it doesn't come to pass until after she's out of office).

It seems that the backlash to her "never, ever come to pass!" line wasn't lost on the Clinton campaign, either...because in the following days, she made sure to emphasize universal coverage more strongly. Here she is on Sunday morning, appearing on This Week with George Stephanopoulos:

STEPHANOPOULOS: Finally, I wonder what your response to this quote from your old friend, Robert Reich, Secretary of Labor under President Clinton. He said you're the most qualified candidate for the political system we now have. But Bernie Sanders is the most qualified candidate to create the political system we should have. How do you respond to that?

CLINTON: Well, look, I'm a progressive who thinks it's important to actually make progress. That's what I've done my entire life. That's what I will do as president. Obviously I have big goals. I want to get to universal coverage; I want to get the economy working for everybody, not just those at the top. Get incomes rising, get women equal pay, raise the minimum wage, have a renaissance in manufacturing, move toward clean, renewable energy -- I have big goals. And I tell you how I'm going to get there and how I'm going to pay for them.

And I think that is what the Americans want. I'm not going to sit here and overpromise and under-deliver. I'm going to tell you what I know we can achieve, and that's going to take the political system we have right now, and then I intend to bring in more people, as always have, 

Notice that in addition to touting the "progressive" line, Universal Coverage has moved up from the 5th position to number one.

Then, last night, in her Iowa victory speech (well...her kinda, sorta victory anyway), she said (2:16, loudly):

I know that we can finish the job of universal healthcare for every single man, woman and child.

There you go. Message least in her campaign speeches, anyway.

OK, so Hillary Clinton is absolutely, definitely, no-guys-for-real-I-mean-it on the record stating that she's going to push hard for 100% universal coverage (note that she specified every man, woman and child, which I would hope includes...dare I say it...undocumented immigrants...but that might be a bridge too far...)

So the question becomes:

  • Since the improvements she's laid out to the ACA and healthcare in general by themselves won't achieve this, and...
  • Since she's now officially on record as supporting "100%, Universal Healthcare Coverage for EVERY SINGLE Man, Woman and Child"...

...what ADDITIONAL steps does she have in mind to achieve that goal, and is she planning on stop if she gets to that point?

After all, the "finish the job" bit, while likely simply a throwaway campaign line, is a bit forboding if you take it at face value.

Would it still be the ugly, messy hodge-podge we have today, a combination of Medicare, private MediGap, private Medicare Advantage, traditional Medicaid, ACA Medicaid expansion, SCHIP, the Arkansas Medicaid "Private Option", the VA, TriCare, private Large Group, private Small Group, ACA exchange QHPs, the ACA's Basic Health Plan provision (BHP), ACA exchange SHOP, off-exchange QHPs, off-exchange ACA-compliant non-QHPs and Short Term coverage (I'm sure I missed a few oddball programs)...but with one or more of these bumped out to somehow cover the additional 30 million people or so???

If so, that would achieve universal coverage, and doing so would be an amazing accomplishment...but it would also still leave a lot of the same other messes to clean up. Millions of people would still be paying through the nose for that coverage via sky-high premiums/deductibles/prescription drug costs and so forth, problems with narrow networks and "surprise" out of network billing would still be a real thing, and so on.

So, I'd still like to have a better idea of what Hillary's game plan would be.

Alternately, if Bernie does end up pulling off a victory, I want to know what he'd be willing to accept short of ​his Single Payer utopian vision. Is he gonna push for the whole enchilada, or is he willing to accept anything short of it...and if so, how much shorter?

With that in mind, I'm writing up my OWN wish list about how to get from the current system to a simple, comprehensive (but probably not pure single payer) system...WITHOUT trying to overhaul the whole system at once.

It's important to bear in mind that while I am trying to take the general concepts of political/economic/logistical realities into account here (which is the biggest problem I have with Bernie's plan), I am not going to delve into the nitty-gritty of which of these ideas/changes could be done via HHS policy changes, which ones via Executive Order (ie, Bernie/Hillary themselves), which would require cooperation by individual state governors/legislators, and which would require Congressional approval. I'll mention some of these here and there, but I honestly don't know where the authority to make some of these things happen comes from. What I do know is that pretty much every one of these, however unlikely to go through, is still more likely to happen than a wholesale replacement of the entire current healthcare system with a comprehensive single payer system within the next 4-8 years.

OK, that's all the backstory/setup. This post is getting pretty long, so I'll stop it here for now. In Part II I'll actually lay out what I have in mind.