Medicare-for-All on the Campaign Trail: Kaiser’s Larry Levitt Explains It All

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Margaret Flinter: Welcome to Conversations on Healthcare with Mark Masselli and
Margaret Flinter. A show where we speak to the top thought leaders in
health innovation, health policy, care delivery and the great minds who are
shaping the healthcare of the future.

This week, Mark and Margaret speak with Larry Levitt, Executive Vice
President of the Kaiser Family Foundation. He has taken a deep dive into
what Medicare for All actually means. He breaks down the various health
reform proposals being talked abou t on the campaign trail and talks about
the shift in the roll of insurance companies should any of them come to
fruition.

Lori Robertson also checks in, Managing Editor of FactCheck.org looks at
misstatements spoken about health policy in the public domain , separating
the fake from the facts. We end with Bright Idea, that’s improving health and
wellbeing in everyday lives.

If you have comments, please email us at [email protected] or find
us on Facebook or Tw itter, we love hearing from you. You can find a show on
www.chcradio.com or wherever you listen to podcast as well. And you can
also hear us by asking Alexa to play the program Conversations on
Healthcare. Now stay t uned for our interview with the Kaiser Family
Foundation’s Mr. Larry Levitt, here on Conversations on Healthcare.

Mark Masselli: We are speaking today with Larry Levitt, Executive Vice President for Health
Policy at Kaiser Family Foundation, he previously served as Editor - in - Chief at
kaisernetwork.org. Prior to his time at the foundation he was the Senior
Health Policy Advisor to the White House under President Clinton. He holds a
Bachelor’s Degree in Economics from UC Berkeley and a Masters in Public
Poli cy from Harvard Kennedy School of Government. Larry, welcome back to
Conversations on Healthcare.

Larry Levitt: Thanks for having me.

Mark Maselli: Y eah, it’s been seven years and we are in the throes of this presidential
election with a very crowded field . I think crowded is an understatement. The
Affordable Care Act, while it remains the Law of the Land. There is sort of a
drumbeat of challenges, on the left you have what appears to be a whole
group of people, I don’t know if they are abandoning the Affor dable Care Act,
but they are moving on to a new iteration of health reform, namely some
form of universal coverage. I am wondering if you could help our listeners
understand the sort of nuance difference between Medicare - for - all, single
payer, universal co verage and maybe put this in some historical context for
us.

Larry Levitt: Yeah, I mean we have been having this debate for well over 50 years,
certainly dating back to President Harry Truman, who proposed the first
formal National Health Insurance plan. T he basic contours of this idea of
national health insurance or a single - payer health plan or Medicare - for - all,

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has been around since then. The terminology has change somewhat, we used
to call it single - payer, now I think kind of latching on to the populari ty of the
Medicare program, is this idea of calling it Medicare - for - all. The idea that
everyone is covered automatically; that the government is sponsoring health
insurance, the government is not employing doctors or owning hospitals so
it’s not socialized medicine. But the government is serving as the insurer for
everyone. Again, everyone is automatically covered by virtue of being a
resident of the United States.

Margaret Flinter: Well, Larry, given some of the impassioned speeches referred during
the deb ates and in - between them. There are some variations even among
the candidates and what they really mean by Medicare - for - all and I agree
with you, I have never heard Medicare spoken up with so much love and
affection, as we have in this current season. Bern ie Sanders generally is
considered to be the most radically sort of far out there on the Medicare - for -
All. And Elizabeth Warren is pretty closely aligned with this idea that you
have got to take the insurance companies out of the equation. But on a
practic al basis, how would that work, in this country to really take the private
insurance industry out of the equation altogether?

Larry Levitt: Yeah I mean, at one level it’s very simple that everyone gets a Medicare card
and everyone gets access to healthcare automatically, with no deductibles,
no copays. At a practical level it’s a really much more complicated than that.
Like the every other high income country has universal coverage. The United
States stands out as the exception, it’s the only country that do es not cover
everyone. But the idea of Medicare - for - All as put forward by Senator Sanders
or Senator Warren, in some ways would leapfrog all these other countries, by
eliminating private insurance, eliminating premiums and deductibles and
copays entirely. But all these other countries that have universal coverage
still preserves some rule for private insurance, whether it’s just supplement
the benefits, which don’t cover everything, in these other countries or to
allow people to jump the queue, to get acces s to care more quickly or see
other doctors or hospitals.

What Senator Sanders is proposing is really a much more expansive version
of universal coverage than we see in any other country. It would certainly be
simpler, it would certainly have lower admini strative cost and profits, but the
idea of eliminating an industry that employees tens of thousands of people
and that is very profitable and very powerful, not only poses kind of difficult
practical issues but also difficult political challenges as well.

Mark Masselli: Larry, obviously there are some variations on the theme of Medicare - for - All,
Senator Kamala Harris has her own version of this, it obviously differs in some
really significant ways, including a 10 year transition period. But maybe you
could dissect her plan a little for us.

Larry Levitt: I think what Senator Kamala Harris is proposing is a plan that tries to capture
the improved access to care and insurance that Medicare - for - All would bring,
but without some of the political landmines involve d. Really kind of two big

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differences in Senator Harris’s plan, one is the 10 year transition as you
mentioned. But I think what Senator Harris is putting forward is that, people
wouldn’t have to wait 10 years, they would immediately get access to
Medicare on an optional basis, the voluntary basis. It would really allow
people to kind of see what this Medicare - for - All plan would look like before
being required to join in.

And then the second is keeping private insurers in the mix, currently in
Medicare tod ay about a third of beneficiaries have private insurance plan,
they are called Medicare Advantage plans. What Senator Harris would do is
keep those Medicare Advantage plans as part of Medicare. It allows the
private insurance industry to compete with the g overnment plan and give
people the choice.

Margaret Flinter: Well, Larry, so we have talked about a few people but when you think
about what Vice President Joe Biden has been saying. He is pretty emphatic
that he wants to see the Affordable Care Act improv ed upon and
strengthened. But some people say that doesn’t really address the cost of
healthcare and that will still remain a problem. Of course we still see some
people who are uninsured. Others like Colorado, Senator Michael Bennet
who authored Medicare - X in Congress are calling for a similar approach.
What’s the hallmark of these more moderate proposals in your view?

Larry Levitt: Yeah, I mean these proposals are being called moderate but they go way
further than anyone could have imagined, when the Affo rdable Care Act was
passed over 9 years ago. These proposals have a few things in common, one
is, they build on the Affordable Care Act by filling in some of the big holes
that still exist in the ACA. One of those is Affordability for middle - class
people, small business owners, self - employed people, farmers, early retirees,
aren’t eligible for any subsidies, any help under the Affordable Care Act and
they have been feeling the brunt of big premium increase, it’s really taking it
on the chin. These proposals would expand the subsidies to these middle -
class people whose incomes are more than four times the poverty level.

The second thing they would do is fill - in what’s called the Medicaid coverage
gap. When the Supreme Court decided that the Medicaid expansio n is part of
the ACA was optional for states a number of states still have not taken up the
expansion, particularly states in the south. Vice President Biden’s plan would
extend coverage to poor people in those states who don’t have access to
anything toda y.

Then the final is this idea of a public option so trying to capture the cost
containment promise of Medicare - for - All, the simplification, but making it
voluntary for people so giving people the option of joining Medicare but not
necessarily requiring o r making it mandatory for everyone.

Mark Masselli: We are speaking today with Larry Levitt, Executive Vice President for Health
Policy at the Kaiser Family Foundation, he previously served as Editor - in - Chief
at kaisernetwork.org, the foundations online hea lth policy, news and

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information service. Hey, Larry, lots of conversations about the cost of
healthcare and there is another side that doesn’t get discussed as much that
obviously, this is an enormous part of our economy up to 20% of our GDP. On
one hand you have people who are talking about the efficiencies that
currently exists in the Medicare program in terms of the administrative cost
that we could lower those. Others are talking about a larger expenditure,
maybe financing some of the additional expans ion. I am wondering what kind
of impact to the GDP would be felt and I know you have done some work on
this, if health companies were taken out of the equation, would we be willing
if we got the results that they get in Western Europe, in terms of outcomes ,
pay what we are paying now. Would we see a benefit to our society, because
what we are seeing in the European countries, what appears to be better
outcomes at a reduced cost. I still don’t believe that you can really reduce
cost with the health industria l complex without a huge struggle.

Mark Masselli: Yeah, well you hear a lot that Medicare - for - All that we can’t afford Medicare -
for - All. I think that confuses a lot of definitions of affordability and cost.
Certainly Medicare - for - All would result in much h igher government
expenditures for healthcare, I mean that’s a feature, not a bug of Medicare -
for - All, the ideas to eliminate deductibles, eliminate copays, eliminate
premiums, but you still have to pay for healthcare and the way we would pay
for it is thro ugh taxes. It would be a shift from paying through premiums and
deductibles, to paying for it through taxes. Certainly government spending on
healthcare would go up dramatically, but what people spend out of their own
pockets and what employers spend would go down.

Now whether we as a nation can afford that, is really more a question of how
overall health spending, regardless of where it comes from changes, under
Medicare - for - All. And that depends on the details, Medicare - for - All would
pay doctors and hosp itals and drug companies less and that would save
money. We would see administrative efficiencies from not having insurance
companies in the mix, it cost about 3% overhead to administer Medicare
compared to upwards of 10% for private insurance. That would all help to
reduce healthcare spending.

On the other hand we would have universal coverage, so the 10% of our
population that doesn’t have any health insurance. Now we would have
coverage and they would use more healthcare that’s the point of giving
peopl e health insurance. And eliminating deductibles and copays would lead
people to use more healthcare and that would boost health spending as well.
Most of the estimates suggest that you know if Medicare - for - all were
implemented in Senator Sander’s bill, we would spend about the same as we
do now on healthcare as a country. So you can’t really say that we can’t
afford it, we would just be paying for it, very differently.

What result would that have on the economy, on outcomes? We spend
double of what the ave rage, other high income countries spends on
healthcare. We will not, in my lifetime I think get down to the level that other

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countries are spending on healthcare. These are the countries spend half of
what we do and they get better outcomes, longer life ex pectancy, better
health, lower mortality. Some of that is due to I think a better organized
health system, greater emphasis on primary care. But frankly some of it’s due
to things these other countries do outside of the healthcare system. While
we spend so much more than the rest of the world on healthcare, they spend
a lot more than us on social services, things like housing and social supports.
And if we could take some of that healthcare spending and shift it to social
spending, we could probably get bet ter health out of it, but that’s a lot easier
said than done.

Margaret Flinter: Well, Larry, one of the great services provided by the Kaiser Family
Foundation which we really appreciate is regular polling of the American
public on a whole variety of aspec ts of health policy. And the polls have
shown pretty consistently that those with health coverage through their
employers are really pretty darn satisfied with their coverage and with their
healthcare, even though I think there is genuine concern and worry about the
fact that copays and high - deductibles are chipping away, somewhat at that
satisfaction. What’s your sense of how consumers feel, generally about the
possibility of a public option or a single - payer system, how does your data
show that trending a t this point?

Larry Levitt: Yeah I mean it’s not like people love their health insurance, I mean you don’t
get into dinner conversations with people raving about their amazing
insurance company. But generally people give their health insurance pretty
good grades. But as you said there are a lot of problems, deductibles have
tripled, in the last decade while wages have risen hardly at all. You know 40%
of people we survey with employer - based insurance say, they or someone in
their family has had some kind of problem affording healthcare in the last
year. So people are not in love with their private insurance, but they are very
anxious about the idea of losing it.

When we ask people do you support Medicare - for - All? Majority of people do
support Medicare - for - A ll. But there is a lot of confusion about what that
means, hopefully this show will help alleviate some of that confusion. For
example, most people who support Medicare - for - All believe that they will be
able to keep their current health insurance which is not the case. If we
present people with the idea that private health insurance would be
eliminated or the government would get more involved in healthcare or
there might be longer waits for services, the kind of messages the opponents
will use in this deba te, support plummets in effect support shifts to
opposition.

The idea of a public option gets significantly more support. We as Americans
don’t like to be told what to do, giving people the option of joining Medicare
sounds a lot better than requiring the m to join Medicare and give up their
current health insurance and I think that’s why you are seeing some of these
ideas like from the transition that Senator Harris laid out or what Vice

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President Biden has proposed, gain some traction, because it eliminat es
some of the anxiety and some of the political downsides of Medicare - for - All.

Mark Masselli: Speaking in sort of the political downsides, I just wonder after all the rhetoric,
if the Democrats win, what do your poll show about what they should do?
And I am sort of thinking about the struggle that President Obama had. He
got through the Affordable Care Act but lost the Congress. In terms of
sustaining this, we have not been able to do with Affordable Care Act, what
we are able to do with Medicaid and Medic are, a good bill but not a perfect
bill that over a number of years, we made important changes that
strengthened and still do. The Affordable Care Act, we have never really been
able to make the types of changes that would have improved an imperfect
bill, which everyone knew it was imperfect. I am just wondering about the
political calculus and where the public might be, to sort of think about past
the election, past everything that people say, where is the right focal point
for the government?

Larry Levitt : Our polling is very consistent, first that healthcare is a top issue for voters
and second when they say healthcare is a top issue, they mean reducing the
cost of healthcare and making it more affordable, that’s what Americans
wanted. Advocates of Medica re - for - All can certainly make the case that
healthcare would be more affordable for many people and cost would come
down. But all of these proposals have tradeoffs. At the bumper sticker level,
healthcare reform idea sound great, once you start filling in the details, and
the tradeoffs become clear and it becomes apparent that they are losers as
well as winners, then they become quite controversial. I mean the Affordable
Care Act was very popular at first and then as time went by, it became less
popular and frankly the only thing that made the Affordable Care Act popular
once again, was Republican efforts to repeal it.

In a campaign, candidates promising to lower healthcare cost and make care
more affordable for people, those ideas will really resonate with voters,
actually putting forward a big complex bill, that will have losers as well as
winners, is probably not going to be a political winner for any incoming
president, that’s been the history that healthcare reform, at the talking point
level is very at tractive politically but the political capital necessary to get a bill
passed, tends to hurt presidents.

Margaret Flinter: We have been speaking today with Larry Levitt, the Executive Vice
President for Health Policy at the Kaiser Family Foundation. You ca n learn
more about their very important work by going to www.kff.org or follow
them on Twitter @kaiserfamfound or @larrylevitt, Larry, we want to thank
you so much for your work, your dedication to keeping us informed abo ut
health policy and for joining us again on Conversations on Healthcare.

Larry Levitt: Thanks for having me.

[Music]

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Mark Masselli: At Conversations on Healthcare, we want our audience to be truly in the
know when it comes to the facts about healthcare re form and policy, Lori
Robertson is an award - winning journalist and Managing Editor of
FactCheck.org, a non - partisan, nonprofit consumer advocate for voters that
aim to reduce the level of deception in U.S. politics. Lori, what have you got
for us this week ?

Lori Robertson: In the latest democratic presidential debate, Senator Kamala Harris of
California and former Vice President Joe Biden disagreed on aspects of their
healthcare plans. Biden, initially said that his healthcare plan would cover the
“vast, va st, vast majority of Americans” but when pushed by Harris, he later
said, it would cover everyone. His own campaign website says otherwise.
Biden’s plan calls for among other things offering a Medicare style public
health insurance option as a choice, an i ncreasing tax credits for individual
purchasing insurance on the Affordable Care Act exchanges. His website says
his plan to build on the ACA will “insure more than an estimated 97% of
Americans.” Harris said as many as 10 million people wouldn’t be covere d
under Biden’s plan. Her campaign told us, she gets to that number by
calculating 3% of the currently estimated U.S. population. That works out to
9.88 million people.

However that figure includes more than just Americans as Biden’s campaign
website said , because not everyone living in the U.S. is the citizen. Biden’s
campaign has reportedly said that under his plan, immigrants living in the
U.S. illegally would be able to purchase insurance through the ACA exchanges
which is not currently allowed. Those immigrants still wouldn’t be eligible for
federal subsidies as campaign explained.

Biden said that Harris’s plan “Will require middle - class taxes to go up not
down.” Harris has proposed her own version of a Medicare - for - All plan that
features an expanded Medicare system including private insurers and is
th
spaced in over a 10 year period. But in a July 29 Medium post, Harris said
her plan to pay for her proposal will “exempts households making below a
$100,000 along with a higher income threshold for middle - class families living
in high - cost areas.” And that’s my factcheck for this week. I am Lori
Robertson, Managing Editor of FactCheck’s.org.

Margarent Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center
at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com , we will have FactCheck.org’s , Lori
Robertson, check it out for you, here on Conversations on Healthcare.

[Music]

Margaret Flinter: Each week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. It’s estimated that the
majority of a person’s lifelong he alth expenditures are often spent in the final
months of life. But death is one of those topics that generates the least

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amount of conversation in the clinical setting in American healthcare. For
folks who end up critically ill or facing a terminal diagnos is like late stage
cancer, this can often lead to poorly communicated, end - of - life wishes being
discussed with the clinician who then often resorts to extreme interventions.

Manali Patel : In oncology notoriously we are underprepared to have these conversa tions
with patient. There is a desire to want to provide patients with truth however
there is this unspoken misconception that by having honest conversations
about prognosis that we are somehow removing the hope that patients are
coming to us looking for. Actually most studies that I have evaluated this
have shown that when you provide honest prognostic information to patients
and allow patients to be part of the decision making about their goals of care,
they are more appreciative of it and actually have m ore understanding of
their disease process and better satisfaction with their care overall.

Margaret Flinter: Dr. Manali Patel is a clinical researcher at Stanford University School
of Medicine. Her earlier research at Stanford yielded in an interesting fi nding,
late stage cancer patients felt more comfortable talking about end - of - life
issues with a lay person as opposed to a clinician. She and her fellow
researchers followed patients at the Veterans Administration Palo Alto
Health Care System for 15 months after they were diagnosed with Stage 3 or
4 or recurrent cancer. Half of the people were randomly assigned to speak
with a late worker about the goals of care over six months period. The
Control Group was given no such intervention.

Manali Patel: We found during the intervention was that she learned as she went and then
at the end, she was completely proficient with having these conversations
such that she came to that realization that these conversations really are not
scary and shouldn’t be scary and sho uldn’t be medicalized and maybe she
didn’t need all the training to begin with. And that’s really the main crux of
this intervention, was finding the right person who can engage in these
conversations.

Margaret Flinter: 92% of the participants who receive the lay person intervention
compared to only 18% of the Control Group were likely to have end - of - life
directives in their electronic health record, often choosing hospice over
emergency room interventions. The average cost of care for the intervention
grou p in the last month of life, was about a $1,000 versus $23,000 for the
Control Group.

Manali Patel: We found the satisfaction of course went up for the patients in the
intervention arm that they went down for patients in the control arm. We
found overwhelm ingly that the patients in the intervention arm were very
satisfied with the decisions that they had made regarding their medical
treatments and regarding their life, but the patients in the control arms,
really did not have much movement at all in terms o f how satisfied they
were.

Margaret Flinter: A low resource patient centered intervention, that assists terminally -

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ill patients, their families and their clinicians to have a frank discussion about
end - of - life wishes, improving patient satisfaction at such a sensitive and
challenging time, that’s a bright idea.
[Music]
Mark Masselli: You have been listening to Conversations on Healthcare, I am Mark Masselli.
Margaret Flinter: And I am Margaret Flinter.
Mark Masselli: Peace and health.
Moderator: Conversatio ns on Healthcare is recorded at WESU at Wesleyan University,
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