The looming public option fight

And other healthcare news.

Happy Sunday to all who celebrate. It is Spring. Spring is good. Take a photo of a flower today.

Here’s a picture of Digby taken by my husband, who is frankly just showing off with his photography skills.

Coronavirus news

The Mercury News published a devastating breakdown of how Bay Area Latinos have suffered so greatly during the pandemic, and how the government response let them down. Latinos make up 50 percent of Covid cases in the Bay Area, despite being just 23 percent of the population. In heavily Latino areas that were hard-hit, testing was far lower than in white areas that had a fraction of the cases, and Latino households are far more likely to be crowded, making distancing harder. One clinic found that 68 percent of construction workers, 77 percent of whom are Latino, were testing positive for COVID-19. (Meanwhile, vaccination rates for Hispanic people are still lagging way behind.)

ABC13 in Houston has found many examples of patients being charged for the Covid-19 vaccine, in the form of “administrative fees” or bills received later, despite the law mandating that patients be given the vaccine without any out-of-pocket charges. I’m reminded of the case I reported a few weeks ago, of a Connecticut senior who didn’t get her vaccine because of a Medicare billing snafu. It’s completely inevitable that healthcare providers and pharmacies would end up charging some patients, or improperly denying them vaccines because of billing, because that’s just how our system is set up—even if, as the providers claimed to ABC13, these charges were mistaken or unintentional. There’s a giant infrastructure, a huge chunk of our economy, set up to bill patients. The wheels kept on turning.

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Like so many other healthcare workers, pharmacists report being overworked, burned out, and terrified of making mistakes during the Covid vaccine push. But it’s not just coronavirus—workloads have increased, especially at chain pharmacies, and pharmacists say they’re no longer able to do things like talking to the patient about their medicines. (That is, the thing a pharmacist is supposed to do). One told NBC: "It's not 'let us care for the patient.' It's 'how fast can we get the people in and out?'" Which reminds me of my conversation with Harrison Kalodimos from this week; the healthcare system, fueled by insatiable capitalism, is running good people who got into healthcare for the right reasons into the ground. Treating patients and people like dollar signs is good for business, and bad for humanity.

Public Citizen published a report this week outlining how Medicare for All would have saved lives during the pandemic. It hurts to read it all laid out like this. I miss when Bernie Sanders was running for president, personally.

My friend Alex Pareene wrote two excellent pieces about the Covid vaccines this week. One on the big problem: How patents on the vaccines, enforced by the US and the WTO, are exacerbating the huge problem of vaccine scarcity in the global south—a problem “spoken and written about as a zero-sum game because of the conditions of artificial scarcity that our government has created and is presently enforcing.” It’s not just “can we send them doses or not,” it’s “why aren’t we letting them make their own?” And the other piece on a lesser problem: Conservative vaccine hesitancy is actually not that big a deal, he argues, at least compared to the problem of inequality in vaccine access at home and abroad. Once white Republicans see their friends and neighbors have gotten the vaccine and not turned into friggin’ gay frogs, they’re likely to come around. Take Pareene’s words as permission to chill out a bit about precisely one thing.

And, via Pareene: This story on how the US worked to undermine the Russian Covid vaccine, Sputnik V, in Brazil is pretty infuriating. The vaccine has been shown to be really good, on par with our Cadillac American ones. Fine, you might say, but there was good reason to be suspicious of the vaccine’s safety last year, wasn’t there? Sure—but the report unearthed by The Washington Post makes clear that the US wasn’t concerned about that, but instead about dissuading “countries in the region from accepting aid from these ill-intentioned states,” because Russia was “working to increase their influence in the region to the detriment of US safety and security.” Can’t let a little global pandemic stop the empire.

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Non-coronavirus stories

Politico reported this week that Democrats are torn on passing a public option, a key part of Biden’s campaign platform. I have some thoughts.

All throughout the campaign, Biden and others pushed the public option as not just a more attainable compromise than single-payer, but actually better than Medicare for All. Joe Biden, and other establishment Democrats, said all sorts of misleading or outright false stuff about Medicare for All: That it would “dismantle” the ACA (technically true, but intended to mislead people they would lose coverage, which they wouldn’t), or that it would be just like current Medicare, with all its flaws (like Nancy Pelosi claimed, which is an inexcusable lie). In March last year, Biden said he would veto “anything that delays providing the security and the certainty of health care being available now,” which is not what Medicare for All would do—it has a long transition period—but again, this statement was designed to actively paint single-payer as worse, instead of a better option that we just can’t feasibly have right now. The public option was supposed to be a really great way of keeping everyone happy—people with private insurance that they loved (?) and people without. This is just something to bear in mind if they drop efforts to pass a public option, either through the filibuster reform Biden recently claimed he’s interested in, or in a reconciliation package later this year: The lie was that this thing is really, genuinely good, not just a way to shut up single-payer heads.

It’s also important to know what sort of public option we’re talking about. Politico reported that the plan will be more likely to get into a reconciliation bill if it’s deficit-reducing. But how you structure the public option—and what sort of goals you have in mind when you do so—matters a lot to whether you can reasonably call it a good policy.

Single-payer is pretty intuitive, in a lot of ways. Everyone’s healthcare premiums are converted into taxes (and made more equitable), so the government pays the hospitals and doctors instead, and everyone who goes to a doctor can be treated for free. But there are a lot of important questions to answer about how the public option would work, because it’s an awkward fix imposed upon a weird, broken system. Is it still going to be possible for people to be uninsured? (Biden’s campaign proposal explicitly admitted it wouldn’t cover over 10 million Americans, roughly as many people as get their care on the ACA exchanges that he loves so much.) If not, how are you going to manage that, and how are you going to ensure uninsured people can get non-emergency healthcare? If the coverage for the uninsured is going to be good, why wouldn’t anyone just choose to be uninsured? Will it cover undocumented immigrants?

Then there’s the huge question of paying for it. Will it have premiums? What about deductibles and co-pays, cost-shifting mechanisms that cause people to avoid care? How big a pay-cut must providers take over private insurance? If uninsured people are covered via reimbursements to providers, at what rate will that be set? Different candidates took different approaches to these questions in their various public option plans, released throughout the campaign. Elizabeth Warren proposed a generous version as part of her Medicare for All ‘transition’ plan, with premiums limited to 5 percent of income and broad coverage. Biden’s was on the less-generous end of the spectrum, hence keeping millions of people uninsured for a laugh.

These aren’t just minor details. As I wrote in 2019, there’s two basic ways to do it: You can make the public option so good that it eventually kills private insurance, because everyone will pick that instead. (If you do this, private insurance will know what you’re up to and spend all their money to stop you.) Or, and this is far more likely given the makeup of the Senate and Biden’s whole deal, you can make it kind of shitty, a backup option for people who aren’t rich enough to get good employer-provided coverage that doesn’t pose a threat to the existence of private insurance. (If you do this, private insurance might still spend all their money to stop you.) This does not pave the way to providing good healthcare as a right to all, or significantly reducing healthcare costs.

All of this is just an exercise in avoiding fights with the healthcare industry for their sins—private insurance existing at all, hospitals and providers charging fake prices, drug companies charging even faker prices. Democratic leadership does not want this fight; see how the stimulus bill expanded coverage by just throwing money at private insurance companies. They’re afraid of the industry funding ads against them, and of losing their campaign contributions, and pissing off the broader Guys Invested In Evil Shit community. But they’re going to have to have that fight if they want to pass a public option, let alone one that’s actually decent. How do you square these two things? Probably by “trying” and failing to pass a public option. You’re up, Joe Manchin. Make it look like it hurts.

That’s all this week; enjoy your Sunday.