How I would design a state single payer law

After providing an analysis of all the issues facing the pushing for single payer health care this country, I thought it was important to provide details for how I would personally design a state-based health care effort. Several states are talking about moving towards a single payer system but for any plan to work it needs to deal with the unique legal and financial hurdles a state would face. I don’t feel the need to do this at the federal level, since a federal single payer system would legally be much easier to implement.

My state plan for affordable universal health care is not what I think would be the absolute “best” policy possible, but the best I’ve been able to piece together that would have a reasonable chance of success given the political and legal hurdles. This strategy is based on four criteria that should be used to judge any proposal:

1. It needs to, on net, make most people better off.
2. Any step forward should weaken or at least not strengthen those institutions opposed to real reform. This is what I consider to be a major failing of the Affordable Care Act. Forcing people to buy subsidized insurance from poorly regulated private insurance companies only increases their power.
3. It should still create a clear path for better improvements even if part of it is struck down by the courts or denied by the federal government. You don’t want a plan that would completely fall apart if one federal waiver is denied or if a court ruling goes the wrong way. If there is a single weak point, that is where it will be attacked.
4. It should keep direct disruption to a minimum. Any real reform is going to need to take on the health care industry, and given the industry’s size there is no way to make this omelette without breaking eggs. That said, there is a big political reason to try to minimize the negative disruption it would cause to regular people.

The plan should be insulated as much as possible from potential political, financial, legal and federal attacks. I think it is important to start with the assumption that any state health care plan for real reform will face a hostile federal government and federal courts. First, history shows it likely will. Second, it is easier to add to a plan that's designed to be built on than it is to take away from a plan where all the pieces were crafted to fit together.

If facing a hostile president and federal courts: A state run public insurer that directly covers many and is open to most everyone

Even if the state can’t get any waiver from federal law or new federal funds, it should be able to build a Medicare-like public insurer, according to a Rand analysis. In addition, the state could automatically sign up most people or give them the option to join this new public insurer.

The state would first set up some type of insurance company. It could be a direct government program, like Medicare, or a corporation owned by the government, like the North Dakota Mill and Elevator.

This public insurer would operate as much like Medicare as possible, to reduce administrative work for providers. This state-based public insurer would offer three plan tiers. Tier one would have benefits, co-pays and out-of-pocket costs equal to roughly what the state currently provides state employees. Tier two would have benefits roughly equivalent to the average plan provided by middle-size private employers. Finally, tier three would be an ACA silver plan for legal reasons.

Auto-enroll state and local employees in tier one

To make this public insurance plan work well, the state would then leverage the health care dollars it does control. The public insurer would handle the state’s Medicaid program. It would also start by gradually transferring basically all state and local employees to the public insurer's tier one plans. This would minimize disruption in coverage for public employees. This large pool would give the public insurer the significant market power necessary to negotiate rates with providers. I would peg provider reimbursement rates to the Medicare rate plus 5-10%. This would allow it to offer insurance at a very good price.

Open it to all employers and add a modest employer mandate

That state would allow all companies regardless of size to buy tier one or tier two coverage from the public insurer. The public insurer should be able to offer a price that would be very attractive to companies, possibly costing more than 10% less than private insurers. It is likely within a few years a significant share of companies would switch. By making the policies similar to what people already have and putting the decision to switch on employers, this also minimizes disruption.

This would be combined with as large of an employer mandate or “pay-to-play” requirement as would likely serve as an ERISA challenge. What exact amount that would be is difficult to guess.

ACA exchange work around

The public insurer would have the tier three plan for one simple reason: To get all the federal ACA subsidies low-income individuals without employer coverage need to sign up for a silver plan on the exchanges.

The state would take action to ensure that the public insurer was basically the only option on the exchange and to make sure everyone qualified signed up. I would create an automatic enrollment and premium collection system for all individuals not covered by their employer.

Since an ACA silver plan is pretty terrible coverage and the subsidies are insufficient, the state would need to provide some extra money to make care truly affordable. The state could create its own cost-sharing subsidies to make tier three coverage the equivalent of tier two.

The money needed for these subsidies would be relatively modest. Some could come from savings in state employee health care spending. Some would come from the employer mandate fine. Some could come from the public insurer adding a small surcharge to the premiums it charges private companies. Some could come from general revenue.

The result

This would not create a true single payer system, but it would get us a lot closer within the constraints we face. Medicare would technically still be separate. Some companies would still give their employers private insurance, but within a few years it is easy to see how 80% of people are directly covered by Medicare or the new state Medicare-like public insurer. It should provide affordable care to almost everyone.

Compared to the other alternatives, it would need minimal new taxes and minimal direct disruption to people’s current coverage. For people with employer provided coverage, the government won’t “make you lose your current coverage.” If your coverage changes, it will be because employers realize it is so much better.

Most importantly, this foundation is easy to build off of if/when the federal government and federal courts are less hostile. The following elements can be added from the beginning if the federal government is willing to provide the waivers or later when a new president is elected.

If the state can get an Obamacare 1332 waiver

The Affordable Care Act does allow the HHS to grant State Innovation Waivers. States can use all of the money that would have been spent on ACA provisions for their own plan if their program will “provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver.”

If a state gets a waiver, this plan could be amended to eliminate the ACA exchange work around mentioned above. Instead, the state could automatically enroll anyone without qualified employer provided coverage in the tier two plan. This would be paid for with the waiver money, the other revenues discussed above and charging these people a “mandatory premium” or new income tax.

If the state can get a Medicare waiver

It is theoretically possible that HHS could grant a waiver to let a state administer Medicare, but it is untested. If the state could eventually get such a waiver, it could just have the new public insurer also operate Medicare in the state. This should streamline administration and reduce health care overhead costs in the state. It would also allow the state to take a more holistic approach when it comes to deciding reimbursement rates.

If the state can get ERISA amended

Dealing with ERISA issues would take an act of Congress, but if Congress does change the law the next step would be fairly simple. This would make reform much easier and more efficient.

Instead of encouraging employers to use the new public insurer, the state would simply require all companies to give their employees the equivalent of tier two coverage or pay a tax equal to the cost. This technically hides the cost while getting the desired outcome. This is not the “best” way to finance health care policy, but it is by far the least disruptive and most politically tenable option. These steps would move my plan from quasi-single payer to true single-payer.

First lay the groundwork

Of course, before we can get to that point, a lot of groundwork needs to be laid. States need to be made ready. On the one hand, that means pushing for legislative changes that weaken the relative lobbying power of the heath care industry. This includes health care regulations like a higher minimum loss ratio for health insurers, a mandate that only non-profit plans can be sold on the individual market, banning surprise billing, etc… It also includes political reforms like campaign finance rule changes, lobbying restrictions, etc…

At the same time, efforts should be underway to build popular support and elect candidates willing to be cosponsors for a specific legislative plan, not a vague idea. Politicians claiming support for vague principles is not as good as public support for a bill. It is easy for cynical politicians to find an excuse for why a specific bill doesn’t apply to their promise or why a bad bill does. This happened a lot in 2009 with Democrats and is especially evident right now as Republicans scramble to figure out what “repeal and replace” means.

That is why I'm putting forward this plan outline. I’m not claiming it is the best possible plan or even the one progressives need to rally around. But it demonstrates what such a plan needs: a realistic way to deal with the legal and political hurdles to any state-based reform.  

What if the literacy revolution created the industrial revolution?

Tyler Cowen recently asked if we would have experienced the industrial revolution if something had prevented Britain from jumpstarting it. He points out Song China and the Roman empire seemed to come close to a breakthrough, but they never did.

I think the problem with this interpretation is it looks at the industrial revolution as a distinct technological phenomena, instead of the natural by-product of the literacy revolution.

I believe the most important invention for the industrial revolution was the movable type printing press. This caused an information revolution without which the industrial revolution would have been impossible -- and it made the industrial revolution nearly inevitable.

After Gutenberg invented the printing press in 1439, the idea of publishing information spread like wildfire. It caused the cost of filling a book with content to drop by more than 30,000-fold, and the rate of publishing grew dramatically. This is what put Europe in general on the path to industrialization. Thanks to the printing press more European books were produced in 1550 (3 million) than were produced in all of the entire 14th century. By 1790, 20 million books were produced in Europe. At the start of the industrial revolution the number and variety of books/pamphlets in Europe reached levels truly unimaginable to Song China or the Roman Empire. You likely had more books produced in Europe in 1790 than produced in the three centuries of Song China.

This resulted in not only a dramatic increase in literacy rates before the industrial revolution but more importantly a dramatic increase in the value of being able to read. Thanks to this information revolution, if one person developed a great idea it could spread easily and allow others to build on it. It was not just the elites that could afford to write and share their thoughts -- even the lowly craftsman could have thousands of his specialty technical manuals produced. If you made a better gear, the world could hear about it.

From this perspective, while Song China and the Roman empire developed some prerequisite machinery, they didn't develop the literacy rates and ability to easily spread information that would be necessary to spark an industrial revolution. Neither empire was truly close. By the same logic it is likely if Britain didn't start the industrial revolution, another European or North American country with a massive literate population would have.

Everything I learned about health care

I have been following and writing about health care policy for almost a decade, and I feel this new series I've produced for Shadowproof is the summation of everything I learned. It at least touches on everything I have learned about how to make universal policy work.

Most importantly, it addresses the political dynamics that are killing, bankrupting, or creating financial strain for countless Americans. The major problem with health care policy is not figuring out what works. We know what works, by looking around the world. The problem is convincing politicians to do the right thing when the industry is spending millions to convince them to keep our system broken but profitable.  

You can find part one here: Road To Single-Payer: How The US Can Achieve Universal Health Care

You can find part two here: Road To Single-Payer: Understanding Different Universal Health Care Systems

It should be around five parts in all, with one part published each week here.

Trump is too ignorant to do health care

During a Wall Street Journal interview, President Trump talked about what could theoretically be a highly risky but successful strategy to get a “win” on health care. He admitted he has broad powers to sabotage the Affordable Care Act exchanges and may threaten to cut off subsidies for millions, so “the Democrats will start calling me and negotiating.”

The real takeaway from this bold admission is not that Trump is considering this strategy, but that he is so ignorant about health care he doesn’t even understand his own strategy.

Theoretically scaring Democrats into accepting a health care compromise might have worked at some point, but it required two things.

First, Democrats need to fear that if the exchanges continue to have problems, voters will blame them at least as much or more than Trump.

This was already tough because polling from before this interview shows voters are more inclined to blame Trump for any problems with the ACA going forward. Of course, polling about how people think they might react two years from now to future hypotheticals is a weak predictor. Obamacare was the Democrats' law, and conservatives are good at spin. Trump’s team could quietly undermine the exchanges with a slew of small regulatory changes that he claims are meant to to help, but actually hurt by increasing uncertainty. The key part, however, is doing it "quietly." People don’t really understand insurance regulation, so as long as the changes subtle, it would create a dicey blame game. Democrats would say Trump ruined the exchange, Trump could say he tried to save them but they were too flawed.

Instead, Trump told a major national publication that he may actively sabotage the law in a big and public way. Now I doubt Democrats are too worried they will get blamed.

Second, to work the offered compromise needs to be better than just letting the ACA exchanges fail.

Using executive authority, Trump could do real damage to the exchanges, making insurance more expensive and unobtainable for millions. So if Trump offered Democrats a compromise that would produce results worse than what we currently have yet better than how it would be if Trump undermined the exchanges, Democrats might feel compelled to think about it.

Instead, Trump has thrown his weight behind the American Health Care Act. If approved it would produce a system even worse than one where Trump sabotages exchanges. Even if some of the exchanges struggle, the ACA’s Medicaid expansion would remain. Democrats are slowly coming to accept that the Medicaid expansion was the best part of the ACA and did the most good. The AHCA would make the individual market terrible and slash Medicaid.

This is not a complicated analysis. This is deal-making 101. If you want to try to coerce someone into making a deal, the deal needs to be better than the threat. You don’t threaten to scratch someone’s car unless they set it on fire, especially while on camera.

Trump's statement suggests he is totally ignorant about what his health care bill would do, what Democrats want, how Congress works, and what he is actually threatening. This is not merely a risk strategy; Trump doesn’t even know enough to understand his own strategy. It is tough to see how he succeeds with any legislation.

As I predicted, Canada is likely to legalize marijuana this year

Another one of my marijuana predictions appears about to come true.

From the CBC:

The Liberal government will announce legislation next month that will legalize marijuana in Canada by July 1, 2018.

CBC News has learned that the legislation will be announced during the week of April 10 and will broadly follow the recommendation of a federally appointed task force that was chaired by former liberal Justice Minister Anne McLellan.

Back in 2014 in my book After Legalization: Understanding the future of marijuana policy, I wrote that this was likely to happen in 2017:

At the same time, several foreign countries will probably adopt legalization. The political situation in Canada regarding this issue is worth watching, because it could put some real pressure on the United States to finally act. In 2013, the leader of the Liberal party of Canada endorsed marijuana legalization, and there is a very good chance his party could win back control after the next federal election likely to take place at the end of 2015. If the Liberals are serious about moving forward with marijuana reform, a smart time to do it would be right after the United States’ 2016 election, when several American states on or near the Canadian border are likely to legalize marijuana.

Despite the fact that marijuana opponent Jeff Sessions has been named US Attorney General, marijuana policy reform continues to move forward. Additionally, marijuana legalization is more popular than ever. I have long suspected that as more Americans see marijuana legalized by neighboring states and Canadian provinces, support will only grow.

The House GOP has literally given up on legislating health care

This headline is not poetic embellishment, it is a disturbing statement of fact: The House Republicans are planning to vote on a major health care bill they effectively admitted they haven’t finished writing. This is what the House Energy and Commerce Committee said about their changes to their now "finished" version of American Health Care Act:

To further ensure older Americans have the help they need to access the care that’s right for them, the amendment to AHCA would provide the financing for additional support for those with high health care costs before the bill goes to the Senate. Under current law, Americans can deduct from their taxes the cost of medical expenses that exceed 10 percent of their income. Our proposed amendment reduces this threshold to 5.8 percent of income.

This change provides the Senate flexibility to potentially enhance the tax credit for those ages 50 to 64 who may need additional assistance.

People who don’t often pay attention to the legislative process may not appreciate what a big deal this is. Effectively, what House Republicans are saying is that they think they should provide an extra $75-$85 billion on tax credits to help older Americans buy insurance, but they don’t want to figure out how.

So instead of writing an amendment to increase tax credits, they wrote an amendment to alter tax deductions -- a change no one wants. The House GOP included this change because it would cost roughly $85 billion, giving the Senate "flexibility" to write their own laws.

To recap, House Republicans are planning to vote for something they don’t support in the hopes that the Senate will remove this wasteful provision and replace it with some tax credit change that costs the same amount.

Whether you agree with a law or not, it should be universally accepted that it is the job of Congress to actually write laws. Regardless of ideology or party affiliation, I would hope everyone can realize what an absurd dereliction of duty this is. Basically, the only job of our elected legislators is to turn their desired policy changes into actual legislation so it can be implemented. We need the actual legislative language to study and understand what our government plans to do.

$85 billion is a lot of money. Deciding exactly how this $85 billion is going to be spent will have massive implications for millions of people and countless businesses. For instance, simply increasing the tax credit for this age group to $7,000 would help the relatively well off, but it would leave the poor without coverage. Using it to improve credits in more expensive regions would help Alaska but do nothing for Ohio. Helping only lower-income adults would require some bureaucratic management. The examples go on.  

Each of the designs would impact other parts of the bill in major ways. That is why these legislative details are so important, and choosing them is basically the sole job of members of Congress. Yet instead of spending a few more days working out these important details, House Republicans have declared they just don’t want to do their job anymore. They may have a vote on a major bill impacting millions of people tomorrow, which they admit they haven’t actually finished writing.

No, really: Democrats should offer an AHCA alternative

Some people on the left are rightly mocking Sen. John Cornyn (R-Texas) for saying Democrats who don't like the Republican Obamacare repeal-and-replace plan should put forward their proposal. After all, the Democrats' already did: it is the current law.

But this is a good chance to highlight differences and drive home the problems with Trumpcare. While the ACA has gotten marginally more popular during this repeal fight, polling shows almost no one thinks the law is perfect, and most want to see it significantly improved.

Democrats could quickly and easily put out a package based on already-scored ideas that would reduce premiums, increase coverage, and lower the deficit. It would do all the things Trump promised to do during the campaign but is now planning do the opposite of with his current repeal-and-replace plan.

It could simply contain a public option, a drug manufacturer rebate provision, and an improvement in exchange subsidies.

Public Option: Back in 2013, the CBO determined adding a public option would save $158 billion over 10 years and offer premiums 7 percent to 8 percent lower than private plans. It would also ensure there would be a reliable option in the huge segment of the country where the exchanges have only one or two insurers.

Require Manufacturers to Pay a Minimum Rebate on Drugs Covered Under Part D of Medicare for Low-Income Beneficiaries: In 2016 the CBO estimated this would reduce the deficit by $145 billion.

Improve Exchange Subsidies: Democrats can set aside $3 billion to make this plan nominally deficit reducing. They could use the remaining $300 billion in savings to significantly improve exchange subsidies. There are many ways to do that, but I would recommend capping what anyone on the exchange pays for a silver plan at 8 percent of their income -- the same limit used in Switzerland. This would fix the very real and deeply problematic Obamacare subsidy cliff. This should also increase the number of people insured.

Since this is a political proposal with no chance of passing, it makes sense to keep it simple, but it would be a smart move. Even if the Republican bill fails, that is not the end of the fight over health care. Paying for their own health care is the top concern for American families. People want to see change. Putting forward this package would show Republicans want to cover fewer people and provide less help to struggling families while Democrats want to lower premiums and provide more help to middle class families. All Democrats need to do is actually care more about helping people than corporate donors, and they can win the debate.