I reviewed Pramila Jayapal's upcoming M4A bill

This [analysis] leaves only two bills worth considering: Bernie Sanders’s “Medicare for All” bill in the Senate and Pramila Jayapal’s upcoming House version, The Medicare for All Act of 2019.

Bernie’s bill comes close, but it isn’t there yet. (I’ve said as much before.) It satisfies three of the four pillars of single-payer. What it lacks is comprehensive coverage. Specifically, Sanders has a lousy plan for elder and long-term care. His bill delegates long-term care to state Medicaid programs—the same process which currently results in the medieval policies causing all this abuse and misery. When insurance companies and other corporations build for-profit nursing homes and then win contracts to administer Medicaid, they just pack their halls with any available body, and reward local lawmakers handsomely for it. Just a few weeks ago, an ex-judge in Arkansas was caught accepting bribes from nursing home companies in a scheme directed by a former state representative. Meanwhile, in Kentucky, the former medical director of a nursing home is passing legislation intended to make it much harder for patients to sue nursing homes for malpractice. It is a perpetuation of barbarism, and it should be a simple fix, but Sanders and the other Senate Democrats haven’t flinched. Until they do, Sanders does not have a “Medicare for All” bill—he has a segregated healthcare bill which inflicts unnecessary and preventable harm on people with disabilities.

Jayapal’s bill, though, appears to meet all of the criteria for a proper single-payer plan. It includes long-term care with a preference toward home health. It sets guidelines for care but lets doctors overrule them. It is, by all accounts, the first actual robust single-payer bill of the post-ACA era. If you are looking for a bill to call “Medicare for All,” this is the one. It must not be permitted to be weakened.

The bill is not perfect. Early commentators fretted when they noticed it dropped a requirement for all providers to become not-for-profit companies in order to be eligible for single-payer payment. This is understandable—we want to “remove profit from healthcare,” after all—but less compelling to me, as “non-profit” is merely a tax designation. Non-profits like the $8 billion Cleveland Clinic, the 78-hospital Ascension health system, or the University of Pittsburgh Medical Center are all non-profits with incredible histories of grift and fraud—UPMC, to me, is best known for opening food banks for the employees it underpays.

A strong series of budgetary tools lets Jayapal’s single-payer program keep providers on a tight leash. One tool is global budgeting, or the advance determination of the national healthcare budget, which is used to set baseline budget agreements for the year and pay hospitals in guaranteed blanket sums based on expected activity. By saying, “last year you spent $2 million dollars, and we can pretty reasonably predict that this year you’ll need $2.1 million dollars for all your services,” the single payer can pay hospitals fairly while minimizing the hospital’s ability to rack up line items and gouge the government. Further tools include prohibitions on providers using single-payer payments for profit, union-busting, marketing, or federal campaign contributions. A single payer cannot remove profit from healthcare on its own (nor could an American NHS), but at least we can give it the muscle to spar with its worst monsters on equal footing.

If the program has all this power to determine how money can be used, I think it should go further in determining how funds for long-term care can and cannot be used—perhaps to guarantee a minimum hourly wage for long-term-care caregivers, alongside increased standards and oversight of LTC services.

Jayapal (and Sanders) also currently leave the Indian Health Service (IHS) alone, though the current IHS funding model is disastrous. The amount spent per-capita for Natives is a third of that spent nationally. This isn’t because Native people have three times better health factors and health outcomes: men on the Sioux Rosebud reservation in South Dakota have a life expectancy of 47 years. Several factors drive this inequity:

IHS funding is dispensed as a fixed amount of money on a predetermined schedule, and is not updated for inflation or cost increases.

IHS hospitals in rural areas often need to contract with private providers for services outside their capabilities, which come at exorbitant rates and receive inadequate Medicare funding.
Removing the block and comprehensively overhauling the IHS budget and permissions would be cheap and relatively simple and should be included in any Medicare for All bill. Next to prisoners, it is hard to imagine a part of the American population so explicitly wounded by racial and economic segregation in healthcare. We must reverse the gears of this misery.

In other news, please meet the second draft of my book.


Writing sucks and I hate it, and editing sucks and I hate it, but editing a paper copy of my own book is really fun? I keep finding all these little pieces of prose that suck, and I get to fix them before anyone else—apart from my ten reader-editors—ever find out.

Here is a link to buy the book, if you want to do that.

The book is done 3/1 and comes out in early August. When I'm done writing it I hope to spend more time learning about prison health, disability health, and Native health. It seems like you can do anything you want to people with disabilities and Native people and people in prison and you suffer no consequences, and I've been fascinated and horrified at how that's played out in health factors and health outcomes. If you happen to have the hookup on how I can talk to more people about their own health, let this guy know.

Between now and then, I'm trying to get my publisher let me record the audiobook; a huge project I am incapable of undertaking. Can't wait!