Medicare for All Could Solve the Problems of Obamacare

Forty years ago, we had a fight about health insurance in this country; a political struggle over how to cover the uninsured. On one side was President Richard Nixon, who advocated bringing the uninsured into the existing system of private insurance through an employer mandate—a law requiring corporations to buy health insurance for their workers. On the other side were the liberals, led by Senator Ted Kennedy, who advocated a system in which Medicare would expand from insuring only the elderly to insuring every American. Because this would make Medicare the only entity to pay many healthcare providers, and thus their only payer, a program of this kind is called a single-payer system. In many other rich countries, such systems of national health insurance are as ordinary as public schools.

For decades to follow, that was the political terrain: liberals supported a single-payer system that expands public health insurance to cover the uninsured, while conservatives supported mandates that expand private, for-profit health insurance to cover the uninsured. To the usually slight extent that radicals concerned themselves with health policy, they admired the Cuban system, in which the government runs the hospitals and the medical schools and systematically allocates medical resources to meet the health needs of the population, rather than the demand of the market.

Those were the old politics of health care. Since President Obama's election and his passage of the Affordable Care Act (ACA), the entire political spectrum has taken a large step to the right on this issue. Now radicals may look longingly to Cuba, but in practice they support single-payer. Liberals, now rebranded as progressives, may quietly pine for single-payer, but in practice they're willing to settle for the plan that Obama borrowed from Nixon. Conservatives today have no plan to cover the uninsured, and they regard their own previous plan with an increasingly unhinged hatred since its enactment by a black Democratic president.

Before the enactment of the ACA, Barack Obama himself supported single-payer, saying as a state senator that, "I happen to be a proponent of a single-payer, universal healthcare plan." As president, of course, he enacted the ACA, a law known to all of its enemies and some of its friends as "Obamacare”. This law creates a system of insurance exchanges on which uninsured, non-poor Americans are legally mandated to buy health insurance. To buy insurance on an exchange, the system has to take you through three stages: eligibility determination, buying insurance and enrollment. Right now all three are dysfunctional, but none would be necessary under a single-payer system.

The first step is to enter your income and some other financial information. If your income is less than 138% of the Federal Poverty Level (FPL), then the system should shunt you off to be covered through Medicaid. If your income is 138-400% of FPL, then the system should send you on to the exchange with a subsidy to help you pay for health insurance. (People with incomes greater than 400% of FPL are required to buy insurance but receive no subsidy.)

Currently, the system is incorrectly sending some Medicaid-eligible people to the exchanges and some Medicaid-ineligible people to Medicaid. Also, many of the subsidy calculations are incorrect, telling people a subsidy amount higher or lower than that which they will eventually receive. These errors of eligibility and subsidy determination are problems in a process that wouldn't exist under single-payer. With all Americans included, there would be no need to decide who was eligible and who was not.

If your income is too high for Medicaid, then the second stage is to register an account on the site, browse the health insurance plans available in your state and choose one to purchase. This is where the most well-publicized computer problems of the ACA exchanges crop up. Some people have tried dozens of times to buy insurance on the exchanges but remain uninsured because the websites don't work properly. This, too, is a problem in a process that would not need to exist under single payer: if all Americans were automatically enrolled in Medicare by virtue of having been born, then there would be no need to buy private insurance from for-profit companies who regard your health care expenses as "medical losses."

Finally, once you have registered an account in the health insurance marketplace and pushed the button on your computer to purchase a particular plan, the exchange's computers must take all the personal information that you entered into their system and send it on to the insurance company whose plan you bought. They do this with an electronic form called an 838, which is a piece of old, simple, reliable technology that has been standard for decades in the health insurance industry, but which the ACA exchanges have somehow managed to mangle. (One individual told the website that he had a spouse and two children, and then for some reason the website lumped them all together and told the insurer that he had three spouses.)

Although these back-end problems have not been as widely reported, they may be the most serious failure of the system. If the administration were to fix all the eligibility and purchasing problems, but not fix these enrollment problems, then people could go through the process online and think they had bought insurance, only to learn upon going to a doctor's office that their supposed insurer had never heard of them. Again, if Medicare covered everyone, then there would be no need for software that communicates between government-run exchanges and private insurers.

Under a single-payer system, the Center for Medicare and Medicaid Service's could simply connect its computers to those of the Social Security Administration and automatically enroll every living person who has a social security number or taxpayer identification number. Thus could all of this confusion have been avoided. We can continue to run 50 state Medicaid systems alongside 50 state insurance exchanges that have to communicate with private health insurance companies. All 100 of those systems have mutually exclusive pools of eligible individuals, plus private insurance through employers, plus labor union plans, plus Medicare for the elderly, plus the Veterans Administration for service-connected disabilities. But it would be far simpler, better and cheaper to enact a single national health insurance system that just covers us all in one risk pool, with everybody in, and nobody out.

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Do You Hear the People Sing, Citoyen Burke?

It is the year 1832, and France is bleeding. King Louis Philippe has reneged on his promise to help the poor of Paris during a time when the economy has tanked and the hardships of disease and poverty bear down on the people of France more than ever. At this point, a brave group of revolutionaries decided that enough was enough. This group was known as the Society for the Rights of Man. Throwing up barricades throughout the streets of Paris that June, the rebels demanded the end of the French monarchy, democratic elections, and relief for the poor. Although the rebellion was crushed within three days, the rebels’ cause lived on to inspire a later rebellion that ended up overthrowing King Louis Philippe. The way most people today are familiar with the facts of this rebellion is through Victor Hugo’s groundbreaking work Les Miserables and the later musical of the same name.

Les Miserables is a unique work due to its portrayal of, well, what the title says it portrays. The miserables; the poor and oppressed people in society who suffer due to the socio-economic system. For two hundred years, readers and audiences have been moved by the struggles of an escaped convict trying to rebuild his life, Jean Valjean, an impoverished factory worker forced into prostitution, Fantine, and Cosette, Fantine’s orphaned daughter. The story’s portrays the June Rebellion as a tragic defeat of the heroic revolutionaries trying to make French society live up to its goals of liberté, egalité, fraternité. Political figures as diverse as author HG Wells and former Venezuelan President Hugo Chavez have praised Hugo’s work for its attention to the oppressed, and also for its defense of the right of citizens to change their society.

This attitude can be directly contrasted with the views of English Whig statesman Edmund Burke. While early in his career Burke defended revolutions such as the American revolution, by the time of the original 1789 French Revolution he had drastically shifted his position to that of a conservative traditionalist. In his 1790 work Reflections on the Revolution in France, Burke attacked the French revolution for its willingness to drastically change society’s political and religious traditions. He argued that overturning France’s tradition of monarchy, aristocracy, and the Roman Catholic Church would lead to chaos. For Burke, society depended on rank and hierarchy, with a few at the top to command and many at the bottom to be commanded. Initially, from the way the revolution went, it might seem as though Burke was correct. The popular image of the French revolution is that of the reign of terror, the period during which the French guillotined many, including some innocents, whom they considered “enemies of the revolution.” But it is here that Burke commits a logical fallacy. He blatantly ignores the fact that under l’Ancien Regime of Louis XVI and Marie Antoinette, hundreds of thousands suffered in poverty and starved to death, or were executed for minor crimes. As Victor Hugo illustrated in Les Miserables, even after the monarchy was restored following the 1789 revolution, the abuses of the monarchy and aristocracy continued.

Burke was correct in that the revolutionaries committed many crimes, but the solution he offers is not based in any logical or well-reasoned thinking. Tradition is one of the stupidest reasons to continue to do something; the idea that “this is the way we’ve always done it” somehow justifies torture and extortion is absurd on its face. Following Burke’s logic, his friends the Americans would never have declared independence, because British imperialism and monarchy was their tradition. Even the Magna Carta of 1215, which Edmund Burke cites as a conservative document preserving English liberties, would never have been drawn up had the English of the time not challenged the tradition of the King having absolute power. Slavery would also have been laudable, as it was a tradition of Europeans since antiquity.

Thus, Burke’s logic falls flat on its face. As Victor Hugo and the Society for the Rights of Man (called the Friends of the Abaissé in Les Miserables) correctly pointed out, following tradition is pointless when that tradition causes harm. As such, the rebels of 1215, 1776, 1789, and 1832 all rose up against traditions that were abusive to the majority of society. Burke ignores the fact that, as Rousseau pointed out, humans have the ability to learn from their mistakes. The revolution of 1789 was bloody, and the revolution of 1832 failed, but the French revolution of 1848 that overthrew King Louis Philippe was far less bloody and was in fact successful. Using our reasoning abilities, people have the power to change the world for the better. Burke was right in one way: we can learn from the past. We can learn from our past mistakes what did not work, and in our next revolution, we can stop ourselves from making those same mistakes.

All of this is important because even in the modern United States we still face a lot of abusive traditions. From the stigma against homosexuality to the struggles of the modern poor, tradition helps promote a number of negative aspects of our society. This is very sad, because it would likely be much easier to get rid of these social ills if they did not have centuries of acceptance which make it hard for people to imagine any other way of social organization.

The final song of Les Miserables is a reprise of the musical’s most famous song, Do You Hear the People Sing, the rousing anthem of the Friends of the Abaissé. This song displays how, although the revolutionaries lost in 1832, the fight continues on. Even today, our fight against abusive traditions continues.

“Do you hear the people sing?

Singing the song of angry men?

It is the music of a people

Who will not be slaves again!”

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