Quora: Analyzing Bernie Sanders' Healthcare Bill

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Answer from Ian McCullough, Consumer technology professional:

I have five standing questions about Senator Sanders' current single payer push at the national level. Those questions remain.

1. Seeing as I would never in a million years buy Trump-branded private health insurance, why should I endorse handing the Trump Administration — or a future one like it, given that the public has proven susceptible to electing someone like him — a public monopoly on all national health care spending?
2. Vermont, Colorado, and California have all had single payer pushes in the past several years. All of them failed. Given those failures, why should we push the policy nationally?
3. Senator Sanders was Chair of the Veterans Affairs committee during the VA Hospital waitlist & record-tampering scandal in 2014, and I was unimpressed by his response in terms of oversight. What can he say that assuages my concerns about oversight being sufficient?
4. In pursuing this bill, will Sanders and his co-sponsors sacrifice contraception, abortion, and other matters that people with ovaries, uteruses, and vaginas have to deal with in order to chase necessary Republican votes?
5. Pushing down provider costs through mandate can potentially help affordability on paper, but what about accessibility? Will this particular proposal drive health care providers and hospitals to close? Am I going to wind up having to travel two hours for a procedure — thus realizing those costs in terms of other expenses?

I'm particularly frustrated about this effort because it sounds like the exact same fight we just had here in California about the Healthy California Act (California 2017 SB 562) except taken to the national level with no lessons learned. If we want to make platform statements or put together bullet points on a campaign webpage, that's all fine and dandy. If — however — legislation is being proposed, then it needs to be examined as potential policy. The details and mechanics need to be specified, even if those details and mechanics change throughout the legislative process. To introduce a bill like this that doesn't define where the funding comes from and how provider compensation is handled is unacceptable. I support Senator Dianne Feinstein's position of fixing the ACA and adding a public option, potentially by way of Senator Brian Schatz's Medicaid buy-in bill or — alternately — Senator Chris Murphy's Medicare buy-in bill.

I actually did a full read-through of the entire bill. What follows are notes I made along the way. These notes are based on a single read and a limited amount of off-the-top-of-my head knowledge of the statutes and programs that are being superseded, so read those notes more as questions than assertions.

• Every time you read "The Secretary shall..." read "Tom Price shall..." Try not to laugh too hard when you do that.
• Note that this says "resident" and not "citizen." This means that they're tying the bill into immigration policy battles as well.

• A four year transition period? Do they really want to let a whole Presidential election cycle pass?

• The specifics of what gets covered is going to matter a lot. This provision will be a lobbyist magnet.

• Here is the scope of care. The words "abortion", "contraception", and "birth control" do not seem to appear in the act anywhere — referring back to question #4 above. "Comprehensive reproductive, maternity, and newborn care" specified in Title II, Sec 201(a)(7) leaves a LOT undefined. More specifically, it leaves defining to the Secretary of Health & Human Services — who, as previously established, is ardent abortion foe, Tom Price.

• Having no cost sharing is a bad idea in terms cost and service utilization. Even a $20, $10, or even $5 co-pay would make a difference. Canada has cost sharing.

• Why does the bill foist Long Term Care onto states rather than managing directly if national single payer is the ostensible goal?

• This is one of the mentions of fee-for-service, which is the model of care that continues to cause market & incentive warping under current Medicare. The ACA actually tried to make headway on this front and get more to paying providers for health outcomes rather than providing services. This seems like a huge miss.

• This here is potentially a huge problem with the proposal. This suggests that providers can refuse to take payment from the government program at the stipulated reimbursement rates and demand cash. If you have a geographic area with weak provider competition, this could create a nasty issue.

• Titles IV, V, and VI are pages upon pages of "The Secretary shall..." Per my earlier comment, it becomes bitterly comedic if you read it as "Tom Price shall..."
• This is the only funding language I've seen thus far that is actually in the text of the bill. Sections 801 and 902 concern the discontinuation of other programs, so — I think — this basically says that revenue associated with SSDI/ERISA and with the operation of the ACA Exchanges will be reallocated to the Universal Medicare Trust Fund. The problems – I think, I may very well be wrong — with this are that messing with SSDI means messing with FICA; that tax stream never hits the Treasury's general fund per the language in the text (so that strikes any money from 801) and the ACA exchanges are self-funded by insurance carriers who pay a fee to be listed on the exchanges (so that strikes any money from 902, since there won't be exchange activity). Someone with more knowledge of this law can absolutely correct me.
  • I know there's a separate document floating around that suggests possible funding mechanisms. My question about that is why none of those proposals were actually included in the legislative text. If there are so many things we could do then pick one, pick some, or pick them all and put them into the actual submitted bill?

• The VA System and Indian Health Service (shouldn't they get that officially renamed one of these days?) are left intact and operating as distinct systems.

• Translation: "Take all of the time and money that was put into building a semi-functional individual market mechanism, rip it up, and flush it down the toilet."

• Title X gets interesting. The transition plan involves two spectacularly colliding directives: (1) Allowing people under age 65 to buy into traditional Medicare — with each successive transition year lowering the eligibility to buy-in by 10 years. (2) Mandating the creation of a public option to be sold on the very ACA exchanges that Section 902 eliminates.

• I also can't help but note that Title X — the Transition section — offers no provision for what happens to the insurance companies, the people who hold stock in those companies (which includes mutual funds held in 401K retirement accounts and in public pension funds), OR the hundreds of thousands (millions?) of Americans who work in either those companies that the act will extinguish or in medical billing on the provider side? That's a lot of livelihoods to disrupt without making some accommodation for those households and families.
• Circling back to funding: Title X, Sec 1001 (c)(1–2) stipulates a monthly premium for the Medicare buy-in option during the transition period where anyone buying in pays the annual per-capita cost spread out across 12 months. Is that the long term funding plan too? If so, then what about poor families who can't afford the payments? How is this an improvement over Medicaid for them?

• In Title X, Medicare Advantage and Medicare Part C — same thing — are referenced in both Sec. 1001, (a)(2) and (c)(3). While I understand that this is the "Transition" second, does this mean that the private insurance companies that run Medicare Advantage plans will be sticking around after all?

What should I know about Bernie Sanders' Medicare for All bill? originally appeared on Quora - the place to gain and share knowledge, empowering people to learn from others and better understand the world. You can follow Quora on Twitter, Facebook, and Google+. More questions:

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