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BernieCare – No; Single Payer 2.0 – Yes.

I don’t see how BernieCare makes it to the serious consideration stage – much less becomes reality. Not because it isn’t a way better healthcare answer than the mess we have today. It just isn’t do-able.

When we do finally ditch the completely unsustainable, inefficient, and idiotic “healthcare system” we have today, I’m convinced it will have most of these components.

  1. This won’t be “Single Payer” as commonly defined, rather it will be a tightly managed, measured, and defined health insurance product administered by various governmental and non-governmental entities.
  2. Everyone will be enrolled.
  3. These will be both not-for-profit and for-profit entities competing in defined markets. Similar to Medicare Advantage, ACA Individual Exchange, Managed Medicaid and other current programs, these entities will bid for programs on a multi-year basis.
  4. Certain populations will be defined separately and bidders will have to demonstrate expertise and capabilities unique to each population. Medicare/Medicaid dual-eligibles will be the most significant of these defined populations.
  5. Winning bidders will have to comply with most of the current ACA requirements such as no medical underwriting, a standardized benefit plan, significantly reduced member cost-sharing, open access to providers.
  6. There will be one universal reimbursement mechanism – likely based on Medicare’s MS-DRGs for facilities and Physician Fee Schedule for other providers. This will be an “all payer, all product” fee schedule, meaning it covers all types of care – including auto, workers’ comp, liability, etc.

Potential variables

  1. This may take the form of Medicaid for All – albeit using a different name (the point made by Dr Jake Lazarovic in a previous post.) I don’t see using Medicare as the basis. Medicaid involves partial state funding – key to get states involved in funding the program. Medicaid also provides a relatively seamless program across all services including long term care, unlike Medicare which separates facility, physician, supplemental, and prescription services into distinct service lines – and doesn’t include long term care beyond relative brief rehab stays. To say these separate programs are confusing and irrational is to be kind indeed.
  2. Employers may be able to provide financial support for their workers, or decide to give their workers higher wages in lieu of a healthcare benefit plan.

However, it’s either this, or BernieCare. And BernieCare is death to insurers and many other stakeholders, while Single Payer 2.0 will be the best of the alternatives.

Next week – yes, this is affordable, and YES, the healthcare industry is going to go berserk.

What does this mean for you?

Massive changes are coming. Survival favors the prepared; extinction is the fate of the willfully ignorant and ideologically blind.

8 thoughts on “BernieCare – No; Single Payer 2.0 – Yes.”

  1. Joe,

    Medicaid is means-tested, state administered, and many states did not expand Medicaid, and in those that did, newly elected GOP governors repealed expansion. So how can you and Dr. Jake (I knew him when I did my summer internship for my MHA degree at Broadspire) say the best option is Medicaid for All. Surely, you know the GOP is so far right and economically libertarian, that they will oppose any version of single payer. One reason I can see that BernieCare may not be enacted is that he won’t win.

    1. Hello Richard – Medicaid as the BASIS is the key. Means testing would go away, universal coverage would be required, and the insurance portion of Medicaid – which is comprehensive and covers all services including long term care – is a much simpler mechanism than Medicare for All. I linked to my earlier piece as to the logic as well.

      Of course the GOP is never going to do anything their corporate masters don’t like – Dems have many of the same challenges. However, we will eventually have a single payer type healthcare system, and the point of this post was to suggest what it might look like – and why.

  2. If the Federal Government goes into healthcare I hope they get rid of insurance and just provide healthcare.

    1. Hello Tony – that’s an option I hadn’t even thought about. Appreciate the thinking.
      cheers Joe

  3. Thanks for your comments and proposals on single payer. I should have been commenting on each of them, but let me “catch up” here.

    I do not know how you get to a single fee schedule. There is no entity that can negotiate for all hospitals and all doctors. Congress would have to be involved also, and their record on imposing lower fees is abysmal.
    And then you get to up-coding. If a new national fee schedule can be manipulated for “complexity”, it will be impossible to meet budget targets.
    I am open to any ideas in this area, of course.

    A second point is that I am not sure the private insurance industry is that scared of even Bernie Care. Private insurers have lost money on most of their ACA business, and with few exceptions like Golden Rule have never liked individual insurance. In group health, there are profits but far less than in the past.

    Insurers have liked Medicare Advantage, because their margins are built into the product. This they want to keep, and they probably would.

    1. Hello Bob, thanks for your comment.
      I’m thinking the Medicare fee schedule would be implemented across the board. Maryland has experience with Allpayer fee schedules and has had some success with it. Other countries have allpayer all product type feeschedules as well. Without an allpYer all product fee schedule, there would be considerable claim shifting and cost shifting as providers seek to game the payer system to shift claims.

  4. I assume that any new medical care structure would apply to both off-the-job and on-the-job injuries and illnesses. If so, the 55% of workers’ compensation loss dollars that are medical would move into health care. This will greatly change approaches to workers’ compensation where return to work becomes even more important to an insurer while medical control is now in a 3rd party’s hands. The 45% of the coverage that is indemnity may be adversely impacted by this change. Coordinating the indemnity and medical sides could be difficult and, perhaps, adversarial, especially when claims are disputed.

    1. Hello Jeff, thanks for the comment/question. My take is that occupational medical care will be separate from the single payer system. Most countries with a single-payer system do in fact separate the two, for very good reasons as you know. Thanks, Joe

Comments are closed.

Joe Paduda is the principal of Health Strategy Associates




A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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