This post stems from both a conversation online with a friend and a series of similar cases that have come through my office lately. And also, the recent cuts to the Affordable Care Act (aka “Obamacare”) subsidies inflicted on Americans by the Republican Party.
Americans - particularly white Americans - tend to see “socialized medicine” as a bogeyman, something to fear, the source of all problems, and on and on.
And yet, Americans depend on the existence of socialized medicine for their survival - at some point in their lives. In fact, I have found that most people - including right wingers - really desire socialized medicine. They just can’t articulate it to themselves, because that would challenge their political commitments.
There are a few myths that prop up this belief, and continue to prevent the United States from joining the rest of the first world (and an increasing number of third world countries) in adopting true universal healthcare.
I have practiced in the area of Medicaid law for over a quarter century. Here in California, we call it “Medi-Cal,” and other states often have their own cute names, but it is all Medicaid. My focus is getting people qualified for Medi-Cal when they need nursing home care, and preventing a claim against their estates for benefits paid. But I also have advised a lot of clients about “community-based” Medi-Cal, Medicare, and other health insurance related issues.
I can say with honesty that the following are true:
(1) When I am able to solve problems for my clients, the solution is always some form of socialized medicine.
(2) When I am unable to solve problems for my clients, it is nearly always because their real need is a form of socialized medicine that the United States refuses to provide for its people.
I also practice law in a fairly Red county. Because senior citizens (55+) are the bulk of my clients, they skew even further Republican than the county generally. I regularly get clients wearing Trump hats and railing on about how all their problems are due to some combination of Democrats, black people, Hispanic people, and immigrants.
In reality, their problems, more often than not, would be far worse if they lived in a Red state, and are caused by a lack of socialized medicine that covers their situation.
This makes it, shall we say, challenging to be a lawyer some days.
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Let’s start with some truths that need to be acknowledged:
For purposes of this post, I will use “socialized medicine” to describe a healthcare system that includes the following:
(A) Universal coverage of a class of people, regardless of health status
(B) Government payment of all or part of the cost
This isn’t an entirely accurate definition, however. It is what most people mean when they use the term.
An accurate description (per the dictionary) is a healthcare system owned and operated by the government - such as Britain’s NHS. This does not include other systems where there is a single payer (the government) but private ownership of hospitals and other providers. The latter is the most common form of universal coverage. It also does not include systems like that of Germany, which uses tight regulation, mandates, and subsidies in combination with private insurers to get the same result.
If you want a quick and easy to understand summary of the systems some different countries use, this website is helpful. You might be surprised at some of the countries with better systems than ours. Just saying.
I use the colloquial definition of “socialized medicine,” however, because arguing about what is and isn’t “socialized medicine” is pointless and futile in most cases.
It is easy to see, with this definition, that the United States already has some degree of socialization of its medical system.
Medicare is socialized medicine.
If you are eligible for Social Security, and are age 65 or older, you receive Medicare, regardless of your income, health status, or employment. Everyone is covered.
Government pays most of the cost (excluding co-pays and co-insurance), using tax dollars. One source (but not the only source) is the percentage withheld from wages as payroll/self-employment taxes. As I will discuss more later, this is one reason many people see Medicare as different from socialized medicine.
But it is, in fact, socialized medicine.
If it were not, then it would be paid by private funds, it would exclude those too sick to be profitable, and insurance companies could kick you off as soon as you cost too much.
People age 65 and older are essentially uninsurable. By that age, all of us are at risk for needing care - and more of it as we get older.
My clients often fail (or refuse?) to understand that literally the only reason they have access to healthcare in their old age is because we as a nation have socialized their medicine.
Medicaid is socialized medicine.
Medicaid is, in my opinion, the most misunderstood Federal program. This is in part because the American right wing has succeeded in demonizing it and those who use it. I believe as well that a factor is the way that states (including California) have changed the name of the program.
If I had a dollar for every person I have heard saying, “I’m not worried about cuts to Medicaid - I have Medi-Cal.” Not realizing, of course, that they are the same thing.
There are other misconceptions, driven by propaganda. The truth?
Most recipients of Medicaid fall into one of these categories:
(1) Low wage workers whose employers refuse to pay benefits
(2) Low income seniors who are retired
(3) Disabled people, including the mentally ill
(4) The minor children of those who are either low wage or disabled
The rest mostly fall into smaller categories, such as college students, caregivers for the elderly or disabled, or unemployed and unable to find work.
There are actually very, very few recipients who are able to work and find employment but do not.
This idea of people freeloading is a myth. A straight-up lie. Access to healthcare doesn’t lead to anyone freeloading. Rather, access to healthcare enables people to treat illness and return to work.
Another truth:
41% of all births in the United States are paid for by Medicaid. This rate is even higher in many Red states - Louisiana is the highest at 64%.
Needless to say, this isn’t because 41% of people of childbearing age are lazy freeloaders - most of them do indeed work. Rather, it is because younger people are likely to have lower wages, and less access to benefits.
Another truth:
Nearly all people in nursing homes are having their care paid by Medicaid. Medicare does not cover long term care. Few of us have $13,000 a month sitting around waiting to be spent. Thus, nearly everyone - the obscenely rich excluded - are getting Medicaid if we need nursing care.
This is where I usually end up assisting people in obtaining socialized medicine.
Medicaid is indeed socialized medicine. If you meet the income and asset guidelines (which vary depending on the specific program within Medicaid you need), you will qualify, regardless of health. The government pays the cost.
Another truth:
Undocumented people do not get Medicaid except in an emergency. And remember, this emergency coverage is there to protect the provider. This means that undocumented people are denied access to preventative medicine, diagnosis, and treatment except when they are actually dying or trying to. (Or if they are in a nursing home, because once upon a time, we didn’t leave old ladies to die on the street.)
That this is stupid, cruel, and hateful is true – and I will look at that a bit in the next post. It is also thoroughly anti-Christian.
The ACA exchanges are socialized medicine
This is another area where misunderstandings are rampant.
“I hate Obamacare - we should get rid of it. I prefer the Affordable Care Act.”
They are, of course, the same thing. And Obamacare is really just the old Republican plan - Romneycare - but because a Democrat enacted it, it is bad, right?
(Beyond the scope of this post is a discussion of the merits and problems with the ACA - that is a whole topic.)
The ACA exchanges were intended to fill the gap between middle class people (who are fairly likely to have employer-subsidized insurance) and poverty level people (who qualify for Medicaid.)
The GOP, through its bought and paid for Supreme Court, and legislative undermining, has chipped away at the ACA. By eliminating the individual mandate (at least the fines which enforced it), people who were currently in good health could (and often did) take the risk of not paying for coverage, since they figured they could always join later when they got sick. And, more recently, but cutting the subsidies, the cost of those ACA plans will skyrocket next year.
Far too many people - particularly in Red states - rely on these plans even as they vote to cut their own throats.
And yet, these are indeed socialized medicine. The plans are required to cover pre-existing conditions, take all applicants, and a significant portion of the costs had been covered by government funding.
As this funding is withdrawn, and people can no longer afford the plans, a death spiral is likely to ensue, driving costs further and further higher until the system collapses.
This is intentional on the part of the Republican Party, which has also voted to make massive cuts to Medicaid. The why is something I will discuss later in this post.
The bottom line is that a lot of people gained coverage through the ACA, and now stand to lose their coverage through no fault of their own, but through the actions of one of our main political parties.
Employer-provided insurance is socialized medicine
Did this surprise you? It shouldn’t. If you get employer-provided insurance, it is universal: you get the insurance regardless of how healthy you are, your age, your income level.
Not as well understood is that it too is subsidized. This happens in two ways. First, the healthier (meaning younger) employees use less, and the extra is used to care for the less healthy (meaning older) employees.
The other is less well known. Because health insurance is an “above the line” deduction, employees do not pay taxes on it. If you count health insurance as part of the wage paid, then that part of the wage is not taxed. Meaning it is subsidized by other taxpayers. I wrote about this a few years ago. The worst part is that high income people get more of a subsidy for their health insurance.
Employer-provided insurance therefore does indeed qualify as socialized medicine - and that is why we all want it, and even make job decisions based on obtaining and keeping this coverage.
ALL of us benefit from socialized medicine, whether we have private insurance or not
This too is a huge misunderstanding that many people have about our healthcare system. It too is the result of a deliberate propaganda misinformation campaign by the right wing.
Have you or anyone you loved done any of the following:
(1) Ridden in an ambulance to get to care?
(2) Been treated in a hospital?
(3) Been treated in an emergency room?
(4) Received healthcare at a rural hospital or clinic?
(5) Needed care in a nursing home?
Guess what? You have benefited from socialized medicine. Because without it, none of these would be able to survive.
This is where a huge misunderstanding comes in. The purpose of socialized medicine isn’t just to pay for care. It is to ensure that the providers of that care get paid.
When you call an ambulance, why does it come? Well, because the company that provides that ambulance knows that it will get paid, whether or not you have insurance. (There are a few exceptions, but they are relatively rare.)
Emergency rooms are required by law to treat anyone who comes in (more about that later), and they can only do so knowing that they will get paid.
And what about after the emergency room, when you are admitted to the hospital for care? That too is only possible because of socialized medicine paying the providers.
Going even further, rural providers - hospitals, clinics, doctors, labs, and more - typically treat a population that is lower income than average, with a majority often on Medicaid. Do you think that such a provider could afford to give away more than half their care without being paid? Of course not. Without socialized medicine, these providers would close.
As would most urban hospitals as well. The only ones that could afford to exist are those that were in places where few people are low wage workers.
My wife is now in management at one of our local hospitals, and has been in on meetings with the local and regional CEOs. And it is ugly - they are literally talking about which hospitals they are going to have to close with even the cuts that the Republican Party made this year. If the ACA exchanges collapse, that is more uninsured people who will have zero coverage except for emergency Medicaid……which is also on the chopping block.
And yes, this problem is even more serious in Red states. Rural healthcare in particular could very well disappear entirely from much of Red state America.
This assumes that the OTHER socialized medicine, Medicare, stays intact. Without that, the senior population would mostly lack the ability to pay. That would pretty much completely collapse our system entirely. Only the obscenely rich could afford to fly to Europe every time they needed healthcare.
Note that when these go away, ALL of us suffer. The ambulance won’t come for us either. The emergency room will be hours away and too crowded to see us. If we get sick on vacation, there will not be a hospital or clinic to treat us anywhere nearby.
At that point, we will be living in the equivalent of a failed state, a third world nation where getting sick or injured means death or disability, not treatment and recovery.
I already mentioned above that nursing homes rely on Medicaid for long term care patients. And on Medicare for pretty nearly everyone there on a short stay.
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Recurring Client Scenarios
I wanted to talk a bit about some scenarios I see in my office all the time. These are not specific cases - I have removed identifying details - and they happen again and again and again and again.
Scenario #1:
Client is in their late 50s or early 60s, and becomes ill with a chronic serious disease that needs long-term treatment and care.
Think of things like cancer, heart disease, autoimmune disease, joint degeneration.
As a result, they miss some work, and the employer fires them or lays them off. Now they get that COBRA notice informing them that they have 60 days to sign up for gap coverage or they lose all health insurance. And this gap coverage costs thousands of dollars per month!
So, they come to me, and all I can tell them is that they are over the income limit for Medicaid (due to unemployment payments, or a spouse’s income). At least we have the ACA, right? Well, those costs just went WAY up - perhaps almost as much as COBRA payments.
What do they do? If they are sick enough, the “best” option they have is to go on Medicaid with a really high “share of cost” - that’s a co-pay they have to make before Medicaid covers anything. For a single person, that means they “get” to keep $21,597 per year of their income (2025 limits - they change each year), which is all of $1,800 per month, not enough to pay average rent even in Bakersfield. So, do they lose their house? Or die of treatable cancer?
Yes, this fucking SUCKS! And this is the stupidity we put up with as Americans.
Scenario #2:
Client is in their late 70s, increasingly frail, and becoming forgetful. They cannot safely live at home.
The best place for them would be in a Residential Care Facility for the Elderly (RCFE) - we commonly call these Assisted Living, Memory Care, or Board and Care.
Alas, these places can cost $3,000 per month or up to a lot more than that. Client only has $2500 per month in income.
So, the only option is a skilled nursing facility, which Medicaid will pay for. And, which costs Medicaid a lot more per month than the RCFE would cost.
So, client gets a worse situation, the government pays more. It’s a lose-lose. At least there is Medicaid to pay for the nursing home. If that goes away, what? People die in their homes from neglect?
Scenario #3:
Young couple is engaged. They get a little ahead of things, and get pregnant. They have no employer-provided benefits, although they do both work. They want to go ahead and get married, but are worried about paying for the pregnancy - even an uncomplicated one is tens of thousands of dollars, and if something goes wrong, they would be financially destroyed.
What are their options? Well, prior to the ACA, not much.
Private insurance would turn them away because of the pre-existing condition. In fact, most plans wouldn’t cover a pregnancy until two years of payments had been made. Yeah, that’s helpful.
Medicaid? Well, that is problematic if they make “too much” money.
The “best” option? She quits her job, and they remain unmarried so his income doesn’t count. And indeed, I have advised clients in this situation to do just that. Have your children, get married after you are done.
Note that this could be even worse: imagine they were already married? The best legal advice I could give them would be to get divorced. And yes, that is crazy!
The ACA, at least, gave options: get insurance through the exchange, with subsidies based on income, making coverage at least somewhat more affordable. This is what the Republicans decided to take away this year.
Scenario #4:
Parents have a child who is profoundly disabled and needs constant care. This includes surgeries, in-home nursing, and more. A LOT more. And this need for care will not end when the child turns 18.
Most private insurance does not cover all of the care needed. Often, not even close. So what is a parent to do?
Well, Medicaid currently steps in, even if the parents have too much income and assets to qualify for benefits themselves. And when the child turns 18, they will qualify for Medicaid for the care they will need for the rest of their lives.
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I could add to this list, of course. The people in other states who find that their entire savings will be spent on nursing home care, or claimed in an estate claim, literally making them worth more to their heirs dead than alive. The people who are suddenly laid off, jeopardizing their access to life-saving medications like insulin - where even the delay in applying for Medicaid or ACA insurance could kill them. The undocumented workers who are ineligible for Medicaid and ACA who end up in the ER and hospitalized with life-threatening conditions that could have been prevented had they had affordable access to primary care and diagnosis.
Our medical system is fucked up and cruel and stupid.
It also costs us twice as much per person than the rest of the first world.
That above is a fact. We pay far more to cover fewer people. And we also get outcomes that are no better - and are often far worse (maternity and infant mortality, for example) than the rest of the first world.
Every one of the scenarios I listed above would be solved with universal socialized medicine.
Every single one.
Imagine if, when you lost your job, your insurance kept on going, whether or not you could afford hundreds or thousands of dollars per month. Imagine if you could get cheaper, less institutional living and care arrangements near the end of your life. Imagine if pregnancy and starting a family didn’t risk financial ruin because your employer refused to provide benefits. Imagine if we treated nursing home care like other healthcare, and paid for it, rather than trying to financially ruin the elderly as punishment for getting old and frail. Imagine if working class people didn’t go without healthcare because they couldn’t afford it. Imagine if we didn’t cruelly punish the people who harvest our crops, build our houses, mow our lawns, and a lot of other necessary yet poorly compensated jobs by denying them healthcare?
We could do ALL of this - the rest of the first world does, after all - but we refuse to.
Why is that?
I’ll talk about that in the next post.
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