Obamacare had two major provisions for reaching the "uninsured," Obamacare exchange plans, the biggest part of Obama's plan and the public option of expanded Medicaid for those within certain limited financial guidelines. Obama took the simple view that some insurance is better than none, over-simplifying the problem to the point of coming to the inaccurately strange solution that having health insurance equals having access to health care.
Over simplifying findings of "studies," [like a 2012, New England Journal of Medicine study: “Mortality and Access to Care Among Adults After State Medicaid Expansions,” by Benjamin D. Sommers, Katherine Baicker, Arnold M. Epstein, New England Journal of Medicine, online July 25, print September 13, 2012, that found that “…expanding Medicaid to low-income adults leads to widespread gains in coverage, access to care, and—most importantly—improved health and reduced mortality,"] Obama created a mythology that magically "having insurance" somehow led to better health CARE, instead of reporting the more accurate [and obvious] conclusion that going from uninsured to Medicaid improved access to care and improved health and reduced mortality, because near free costs of obtaining and of USING health insurance led to better health care than having none.
But Obama stuck with his magical over-simplified thinking that having any health insurance improved health, which even the silliest among us knows is untrue, because having health insurance that you can't use because of the expense of deductibles, copays, coinsurance and exclusions means all you have is a card that says you're insured, which does not improve your health.
And so, we know from Obamacare that focusing on the number of uninsured is only relevant if the insurance available actually COVERS the risk of becoming sick or injured. This is the persistent problem of being UNDER-INSURED, a problem that Obamacare arguably worsened by selling the false premise that having insurance was equal to health care, regardless of how little risk was covered.
In fact, with the false premise that having health insurance magically equals access to health care, Obamacare was off and running, and embracing that false concept, went on with its next false concept that having free checkups would improve health even as we saw the cost of TREATING any illness discovered by such free testing skyrocket from the cost of further testing required, to provider care, to the cost of medications.
In other words, the cost barrier represented by the increased costs to consumers of actual needed health CARE skyrocketed under Obamacare. This was for many reasons, but most obviously because the law embraced low-level preventive care guarantees and then merely required that insurance policies cover certain things (10 essential benefits) WITHOUT imposing limits on how those needed services were covered in terms of raising consumer out of pocket costs for deductibles, copays, coinsurance and exposure to increased exclusions from coverage.
OK, so merely addressing the number of uninsured without addressing the under-insured, is a political numbers game and what consumers should look for are candidate solutions to the problem of under-insurance. The problem of under-insurance will not improve under Medicare For All, and in fact could get worse for consumers because Medicare For All washes its hands of anything it doesn't cover and leaves it to the private sector of "INSURANCE CONTRACTS."
To their credit, Bernie Sanders and Elizabeth Warren at least noted the problem of having insurance that is too expensive to use, under-insurance. However, under-insurance under all candidates remains and is perpetuated, much like the Obamacare myth that somehow having insurance is some magical thing that will improve access to health care without paying serious attention to what that insurance covers.
The debate moderator started with a question directed to Bernie Sanders about how Sanders has consistently refused to say how much Medicare For All will cost. "Don't voters deserve to see the price tag?"
Senator Sanders began: "Medicare for all will end the absurdity of the United States paying by far the highest prices in the world for prescription drugs and healthcare in general while we have 87 million uninsured and underinsured and why 30,000 people die each year waiting for health care because of the cost."
While media will try to hone in on the accuracy of 30,000, which is another "maybe" number like all the numbers thrown out, much like the 87 million uninsured and under-insured, or Obama's offered number of 49 million uninsured, Sanders at least acknowledges that the problem is the uninsured AND under-insured if you're addressing cost as a barrier to health CARE, which using his number of 87 million is about TWICE AS MANY PEOPLE as Obama used to justify his plan a decade ago.
But there is a problem with Bernie Sanders and that is that Sanders asserted in the debate that "Medicare For All, which will guarantee comprehensive health care to every man, woman and child will cost substantially less than the status quo." That statement is only truthful regarding the word "COMPREHENSIVE," if you refer to the fact that in the Sanders bill there is a section called "Comprehensive benefits," under Section 201, which are in fact NOT COMPREHENSIVE.
Look for yourself and find out that cancer care, surgery, transplants, all the bankrupting needed services for the sick and injured are NOT included. Which means that Medicare For All's Section 303, private insurance contracts which could easily lead to consumer financial ruin are all the more relevant.(Further consideration in this blog, "2020 New Year Concerns: Why the Hell Are Consumers Trusting Congress on Health Insurance? Part IV").
VP Joe Biden doesn't address the problem of under-insurance in the debate.
Tom Steyer doesn't address under-insurance.
Senator Klobuchar also didn't address underinsured.
Mayor Buttigieg merely embraces the Obamacare mythology that "having health insurance" means having health care and in the debate brags that his priority is, "making sure that there is no such thing as an uninsured American," AND he supports the individual mandate, "because the system doesn't work if there are free riders."
Senator Elizabeth Warren touches on the under-insurance problem stating: "I started this by talking about 36 million Americans including Americans with insurance who just can't afford to have a prescription filled." She goes on to state that she'd make three things more available, and she mentions them twice, HIV-AIDS drugs, epi-pens and insulin. Those are the Warren lottery winners, everyone else is left with Elizabeth Warren's agreement with Bernie Sanders' plan which leaves consumers in physical and financial jeopardy "INCLUDING AMERICANS WITH INSURANCE," which is the very definition of under-insured.
The candidates' statements lead to a single conclusion, COST AS A BARRIER TO NEEDED HEALTH CARE AND SERVICES is not going to improve under their plans.
If the problem of under-insurance is that consumers with insurance STILL can't afford the care they need for medical illness or injury, the ANSWER is to ensure that these costs are covered, whether it's through the product of health insurance or some other government-created mechanism.
No such luck from these candidates.
While they all brag about thinking big for this decade's ideas, their ideas are throwback models of failure, leaning heavily on the weaknesses of Obamacare where service contract type coverage of finite costs of checkups is provided "free" while the bankrupting costs of needed medical services and care leave consumers vulnerable to both physical and financial ruin because of cost.
For all the big talk, our government is NOT ready to actually reform our industrial health complex. There is no talk of ABSOLUTE out-of-pocket maximums, whereby a public funding option is available for individuals who spend a certain amount annually for any NEEDED medical expense that is NOT covered, eg is excluded by insurance that a person carries.
There is no talk about governmentally imposed LIFETIME PRICE CONTROLS on the MAXIMUM AMOUNT that can be charged for any NEEDED MEDICAL SERVICE.
There is no talk about DEBT FORGIVENESS, [much like proposals for the elective choice of student loans,] where if a person pays a percentage of their medical bills, whether it's at once or over a period of years, that the rest of that bill is forgiven.
There isn't even talk about a government policy and plan that prioritizes for government and rewards private insurance companies for effectively going after fraud instead of merely "accepting" the billions of dollars in insurance fraud that are passed on to consumers, or, which, like Obamacare DISCOURAGE efforts to go after fraud with the 80/20 idea that talked about 80 percent of premiums going for payment for claims and 20 for everything else so that going after fraud eats into insurance company profits.
The candidates leave us where or worse off when it comes to under-insurance, paying for health insurance through taxes or direct premiums AND being unable to afford needed medical care and services.
