OK, so what about HILLARY's healthcare plan?

Last night I bit the bullet and posted a "quasi-endorsement" for Hillary Clinton in the Democratic Presidential Primary. I say "quasi" because I never came right out and actually stated that I think other people should choose her over Bernie Sanders. What I said was that I have serious concerns about her, but when it comes to the subject of healthcare, I find myself coming to the conclusion that as much as I may support a single payer (or some similar type of universal coverage) healthcare plan, I just find Sen. Sanders's just-released plan to be a) too vague even as a broad, general outline and b) too unrealistic even as a negotiating starting point.

While the response in the comments here has been calm and reasonable, the response from some Sanders supporters over at Daily Kos was...well, "passionate", to put it mildly. Many people were supportive, some offered reasonable rebuttals and counter-arguments...but a certain subset accused me of being a Hillary shill, a GOP stooge and so forth, claiming that I never actually supported single payer in the first place (and that I don't now, even though it was the approach and timeline which I was debating, not whether SP is the way to go at all).

Here's what I wrote in my F.A.Q. 2 1/2 years ago, when I first launched the ACA Signups project:

What do you really think of the Affordable Care Act?

I think it's a huge, cumbersome, insanely overcomplicated law that creates a ton of headaches.

However, I also think that the healthcare system in the United States prior to the ACA was already cumbersome and overcomplicated, with its own headaches...and that it was hurting poor and middle-class people in terribly unfair and immoral ways. There are some elements of the ACA which I don't like one bit, such as it being a windfall to the for-profit health insurance industry...but I feel that the good that it does outweighs the bad. If it works as intended, itshould stop some of the worst abuses of the industry, bring decent healthcare coverage to millions of people who didn't have it before, force insurance companies to use at least 80% of their premium revenue for actual healthcare costs, and pave the way for individual states to switch to single-payer plans if they so choose in the future.

So yes, overall I do want the ACA to work. However, wanting it to doesn't mean that it will. ACASignups.net was created to try and get a sense of whether or not it is working.

Well, it's 2 1/2 years later, and the answer is that the ACA is kind of, sort of working. Some of it is working very well, some of it hasn't, some of it is still too soon to tell. The question is whether to keep and improve upon it, or scrap it and replace it with an all-new system. Hillary believes the former, Bernie the latter.

One thing I didn't notice about my previous diary until after the comments started flowing is that it really isn't a comparison of Bernie's plan vs. Hillary's; it's a comparison of Bernie's plan vs. my plan for achieving some form of single payer/Medicare for All system.

Note: When I say "Single Payer" I'm also open to any number of not-quite-single-payer systems; for instance, even Canada's system still has co-pays and the like for some procedures:

Private health expenditure accounts for 30% of health care financing. The Canada Health Act does not cover prescription drugs, home care or long-term care, prescription glasses or dental care, which means most Canadians pay out-of-pocket for these services or rely on private insurance. Provinces provide partial coverage for some of these items for vulnerable populations (children, those living in poverty and seniors).[3] Limited coverage is provided for mental health care.

My idea is to keep the ACA in place--along with Medicare, Medicaid, ESI and the individual markets--for the time being, while slowly, gradually expanding Medicare down the age line literally one year at a time (64...63...62...etc), which would shift 3-4 million people at a time (including around a quarter-million uninsured folks) over to Medicare coverage with each phase, while giving a year between each move to allow Medicare itself, the private market, the hospital/healthcare provider system and the economy in general time to absorb the change and adjust accordingly.

Is this the best way to do it? Perhaps not. One commenter suggested starting at the other end, by having every newborn enrolled in Medicare at birth and moving the line up the age ladder instead. There are other methods as well, but the point is that it would have to be a gradual process which, yes, would take a decade or longer. Eventually we would hopefully get to the point where pretty much everyone would be covered by some overlap of Medicare and Medicaid, and could then phase out the ACA, having served us very well in its role as a transitional tool.

Anyway, that's my idea. During this period, however, the ACA itself would still require a lot of improvements and tinkering, and that's where Hillary's ideas would presumably come into play for the next 4-8 years. Unfortunately, I was so focused on Bernie's plan and my own, I embarrassingly forgot to take a look at what Hillary has actually proposed. Angela Marx called me out on this, and rightly so.

So, what does Hillary Clinton have to say about her plans for healthcare in America, beyond her promise to generally defend and improve the Affordable Care Act? Well, she's posted the following "factsheets", each of which is at least as detailed as Bernie's entire 5-page single payer outline to completely overhaul the entire U.S. healthcare system (I'm only posting the main bullet points; the actual links give far more in-depth discussion of each):

Hillary Clinton’s Plan for Lowering Out-of-Pocket Health Care Costs

Hillary Clinton has defined the central economic challenge of our time as getting incomes rising for hard-working Americans. But for too many, their out-of-pocket medical costs are growing much faster than their wages, meaning too much of their hard-earned take-home pay goes to paying deductibles, copays and coinsurance for medical expenses.

...While it is true that national health expenditures have grown more modestly in the past few years, and many employers have experienced comparative savings, working Americans have not seen similar savings in their own pockets. Hillary Clinton has a plan to change that. Her plan will build on the Affordable Care Act to reduce cost-sharing for ordinary doctor visits, and create a new tax credit for Americans facing excessive out-of-pocket costs. In combination with new limits on out-of-pocket and drug costs for American families, her plan will make sure that Americans see the out-of-pocket savings they deserve.

• Build on the Affordable Care Act and require plans to provide three sick visits without counting toward deductibles every year.
• Provide a new, progressive refundable tax credit of up to $5,000 per family for excessive out-of-pocket costs.
• Protect Americans from surprise medical bills.
• Enforce and Broaden the ACA’s Transparency Provisions.
• Strengthen authority to block or modify unreasonable health insurance rate increases.
• Vigorously enforce antitrust laws to scrutinize mergers and ensure they do not harm consumers.
• Reduce health care costs by building on delivery system reforms that reward value and quality.
• Encourage the next generation of health innovation and entrepreneurship.

Hillary Clinton’s Plan for Lowering Prescription Drug Costs

Hillary Clinton believes we need to promote competition and leverage our nation’s bargaining power to lower drug costs on behalf of Americans. Hillary Clinton believes that we need to hold drug companies accountable to lower drug costs for Americans. And this isn’t a new fight for her. She fought against special interests for affordable health coverage in the 1990s and as a Senator. In her 2008 campaign, she called for allowing Medicare to negotiate with drug companies to reduce prices and rein in costs. She’s been committed to this fight throughout her career, and is continuing it today.

• Stop direct-to-consumer drug company advertising subsidies, and reinvest funds in research.
• Require drug companies that benefit from taxpayers’ support to invest in research, not marketing or profits.
• Cap monthly and annual out-of-pocket costs for prescription drugs to save patients with chronic or serious health conditions hundreds or thousands of dollars.
• Increase competition for prescription drugs, including specialty drugs, to drive down prices and give consumers more choices.
• Clear out the FDA generic backlog
• Increase competition for specialty drugs including new “biologic” drugs – which are often the most expensive new treatments
• Prohibit “pay for delay” arrangements that keep generic competition off the market.
• Allow Americans to import drugs from abroad – with careful protections for safety and quality.
• Ensure American consumers are getting value for their drugs.
• Demand higher rebates for prescription drugs in Medicare.
• Allow Medicare to negotiate drug and biologic prices.

Hillary Clinton’s Lifelong Fight for Quality, Affordable Health Care for All Americans (I've skipped over some bullet points, including ones which overlap with the other entries)

• As First Lady, she refused to give up when the insurance industry defeated health care reform. Instead, she worked with Republicans and Democrats to help create andimplement the Children’s Health Insurance Program, which now provides health coverage to more than 8 million children.

• In the Senate, Clinton championed lower prescription drug prices for American consumers: she fought for Medicare to be able to negotiate for fair drug prices, supported getting generic drugs to market faster, and consistently backed safe prescription drugimportation from other countries.

• Following the terrorist attacks of September 11, 2001, she pushed the Bush administration for $20 billion for recovery, and she helped steer funding to start a medical screening program for Ground Zero workers and responders, which provided the “first statistical glimpse” into the health effects of the World Trade Center collapse, cleanup and recovery efforts. She also introduced legislation to speed up benefits to families of public safety officers who died in the line of duty responding to the 9/11 attacks, and she championed the James Zadroga Act to reopen the 9/11 victims compensation fund to new claims from first responders.

(as President, she will...)

• Defend the Affordable Care Act. Clinton will continue to defend the Affordable Care Act (ACA) against Republican efforts to repeal it, while expanding on its successes to broaden access to care.
• Ensure women have access to reproductive health care. As Senator, shechampioned access to emergency contraception and voted in favor of strengthening a woman’s right to make her own health decisions. As president, she will continue defendingPlanned Parenthood, which provides critical health services including breast exams and cancer screenings to 2.7 million patients a year.
• Prevent, treat and make an Alzheimer's cure possible by 2025. The signature piece of Hillary Clinton’s commitment to target and defeat the diseases of our day is a groundbreaking $2 billion investment in research to prevent, effectively treat and make possible a cure to Alzheimer’s disease by 2025.

OK, so that's her plan (or rather, a cluster of mini-plans). On the surface, many of these sound like just "tinkering around the edges" and so forth, and some of these ideas may be non-starters or may not make that much of an impact even if they go through...but every one of them is reasonable and workable without completely blowing up the system, and some of them could result in significant improvements to the ACA, which could in turn have a positive ripple effect. For instance, one of the biggest complaints people have which prevents them from signing up for exchange coverage is, of course, the excessive deductibles, co-pays and prescription drug costs. If Clinton's ideas were to go through and worked out as she hopes, this could significantly increase the number of enrollees the following year, which in turn should help improve the overall risk pool, which should (in conjunction with the strengthened rate review program she has in mind) result in premiums being kept in check and so forth...as well as deductibles not continuing to shoot up further. Again, none of this is sexy, but it's the under-the-hood tinkering which will hopefully keep the ACA chugging along and improving.

In the meantime, presumably she'd be negotiating with the Governors of the remaining 19 non-expansion states to finally get Medicaid expanded, which (if successful) would reduce the uninsured population by up to another 3 million people (over 10% of the remaining total).

Having said that, Greg Sargent of the Washington Post agrees that if we're gonna give Bernie the 3rd Degree over his intentions, the same should be asked of Hillary:

And so, in Clinton’s telling, the argument is not over whether to strive for universal health care, but how to get there. (Her campaign has also misrepresented Sanders’ goals in some ways, but let’s put that aside for now and focus instead on this broader dispute over the best path to that stated goal.)

The fair question for Clinton is: How, in detail, would you go about building on the Affordable Care Act to cover the remaining uninsured?

Right now, an estimated 28.5 million people remain uninsured. I spoke today to Larry Levitt, a senior vice president at the Kaiser Family Foundation, and he suggested a number of policy ideas that could theoretically be adopted to help cover those remaining uninsured by building on Obamacare:

1) Further incentives for getting states to expand Medicaid.

2) More and better outreach.

3) Spending more money. Levitt notes that a lot of people who are eligible for ACA subsidies may still be facing prohibitively high costs. “

4) The public option.

...If it is true that Clinton is being more realistic about the constraints the next Democratic president will face, she could be asked for more detail about how she’ll move towards her goal of universal health care within those constraints.

But what about universal coverage? Well, I described the route which I think would work best, but there's already another route which we could take to achieve a "single payer" like system at the state level...and it can be found in a little document called...The Affordable Care Act:

In Colorado, unhappiness with the law has added momentum to an effort to replace it with a government-run health care program that would largely cut private insurers out. The initiative qualified for the 2016 ballot this month after supporters submitted over 158,000 signatures.

State Senator Irene Aguilar, a Democrat, said frustration with rising premiums and deductibles had fueled disillusionment, as had the recent collapse of a nonprofit cooperative that was the most popular insurer on the Colorado exchange.

The new system would be expensive, raising $25 billion a year in revenue from a 6.67 percent payroll tax on employers and a 3.33 percent tax deducted from workers’ paychecks.

It's a good article overall, and as a single payer advocate myself, I'm rooting for the Colorado initiative to succeed on both the ballot and in practice...but the framing of it as "abandoning" the Affordable Care Act is incredibly unfair to the Obama Administration and those who wrote the law, and I wish both opponents and supporters of single payer would stop phrasing it that way. Doing so is just as bad as, for instance, Republican Governor Rick Snyder and the Detroit News praising the "Healthy Michigan" program without mentioning that it was created by and is funded by the ACA.

Assuming it's successfully enacted, the proposed ColoradoCare system would be very much enabled BY and partly financed BY the Affordable Care Act itself.

Don't believe me? Here's the official explanation booklet:

How would it be funded?

It would be funded with Affordable Care Act (ACA) waiver funds granted to states that can innovate with their own plans to achieve or surpass the goals of the ACA, by Medicaid waiver funds, and by a Health Care Premium tax on payroll and non-payroll income collected by the Department of Revenue.

The design and operation of ColoradoCare will be determined by existing legal and market conditions.

ColoradoCare requirements and powers are described in the Amendment. The Affordable Care Act (ACA) waivers require that ColoradoCare meet or exceed all the guarantees of the ACA.

How are the current health care market dynamics dysfunctional?

There is a well-known problem called “adverse selection” in health care insurance. A high-quality, accessible, and low-cost plan is unprofitable to insurance companies because it would attract people with high health care needs. In other words, a better product adversely selects for consumers who cost too much money. The Affordable Care Act addressed part of adverse selection by prohibiting pre-existing condition exclusions, but there are many ways to attract the healthy such as offering high-deductible policies. The adverse selection dynamic overpowers the incentive for high-quality, accessible, and low-cost plans.

The passage of the Affordable Care Act (ACA) in 2010 gave states an unprecedented opportunity to use an ACA Section 1332 waiver, which allows states that can meet or exceed ACA standards to use the ACA funds to design their own health care financing system. In 2010, Dr. Irene Aguilar was elected to the Colorado State Senate, and she introduced the Colorado Health Care Cooperative proposal, a universal health care proposal, into the Senate (SB11-168).

Have I made myself clear? Yes, most of the funding of ColoradoCare would be from new state taxes and from shifting funds currently going to Medicaid (apparently Medicare, VA and Indian Health Service enrollees would stay put but have their supplemental coverage provided for by COCare). However, a large chunk of it (around 1/3 of total funding, I believe) would be provided for by the funds currently going to the ACA's tax credit, cost sharing reduction and Medicaid expansion funds.

This, to me, is one of the most important, and least talked about provisions of the Affordable Care Act: It specifically and deliberately creates a pathway for the ACA itself to be "replaced" down the road...as long as the "replacement" is at least as good, if not better, at achieving the ACA's goals. And even then, assuming they use the route Colorado is pursuing, the ACA would still be in place as a funding, regulatory and guidance mechanism.

Frankly, between Republican politicians taking credit for Medicaid expansion in general, Kentucky trying to pretend that "kynect" is somehow separate from "Obamacare" and now this, I have to imagine that President Obama is feeling a little like Dustin Hoffman's character Stanley Motss from the film "Wag the Dog".

Of course, Colorado only has about 5 1/2 million people, and there's no guarantee that the ballot initiative will go through in the first place...but it has a hell of a lot better chance at the ballot box in Colorado than it does of getting through Congress at the federal level. And given that Bernie's whole campaign is based on the "massive uprising of the people", this seems to be the perfect way to test such a thing out: If the people of Colorado are willing to rise up and demand single payer healthcare en masse, that would absolutely inspire other states to do the same thing. Of course, this assumes that the Colorado initiative works once it gets through.

Colorado isn't a huge state, but it has a large enough tax base that it should be able to avoid many of the problems which doomed Vermont when they tried it last year. In addition, Colorado's plan is clever in that it keeps Medicare, the VA and the IHS in place...which would reduce the disruption factor (both economically as well as in terms of people's current coverage) by around 20%.

Of course, even if Colorado manages to pass their own ACA-supported SP initiative, and even if it proves to be wildly successful, it would still probably take another decade or more before most other states follow in their footsteps (I'd imagine that Vermont might form a regional SP initiative with NH and other small Northeastern states)...and even then, the best likely outcome would be similar to the Medicaid expansion situation today, with 31 states on single payer and 19 refusing to budge. However, that would still be a massive improvement over where we are today...and is still far more likely to happen than an all-at-once, federal Single Payer initiative happening.

The point is that there are existing tools to achieve these goals which are far less disruptive while having a greater chance of succeeding.