Concepts of Plans for Debt and Death
Kamala Harris, the National Democrats and Health Care
The U.S. health care system spends twice as much money per person on average as other wealthy countries, delivers fewer hospital stays and doctor’s visits, allows thousands of people to die without needed treatment and pushes millions of people into bankruptcy. If the polls are correct and only former President Donald Trump and Vice President Kamala Harris have a realistic chance to win the Presidential election, voters should expect the extreme spending and mass death to continue for at least four more years.
Trump earned well-deserved mockery for saying he has “concepts of a plan” to replace the Affordable Care Act in the September 10 televised debate. Harris was smart enough not blurt out a damaging soundbite, but her rambling answer revealed a core policy agenda based on the same vague “concepts of a plan” as Trump’s. Moderator Linsey Davis pointed out that Harris briefly supported Medicare for All during the 2020 primaries but abandoned it for a corporate-healthcare-sort-of-for-all-option, and asked Harris what she supported now. In a dizzying game of policy pinball, Harris:
pivoted back to gun control;
then talked about John McCain’s vote against ACA repeal;
said "the plan is to strengthen the Affordable Care Act not get rid of it”;
jumped to Medicare prescription drug price negotiations;
Closed with an emotional reminiscence on pre-existing condition exclusions outlawed by the ACA, as if private insurers haven’t spent the last 14 years unreasonably denying payment for the very same allegedly “covered” services.
That’s it. The Vice President offered no details on how her Administration plans to “strengthen” the ACA, largely because she has no more plan than Trump.
The best source for health care promises from Harris and her running mate, Minnesota Governor Tim Walz, is the campaign’s 81-page economic policy proposal “A New Way Forward for the Middle Class: A Plan to Lower Costs and Create an Opportunity Economy.”
Campaign dynamics dictate shifting messages, so it’s not surprising that the campaign’s issues web page has different headings than the chapter titles in the full pdf. Neither mentions the most significant Harris/Walz proposals - adding vision, hearing and some form of home health benefits to Medicare, which the campaign described in an October 8 “Fact Sheet.”
These ideas could become valuable improvements in a threadbare health care safety net for people 65 years and older and disabled Americans. However, Harris and the national Democratic Party remain committed to a system that spends twice as much money per person as other comparable countries, while nearly half the adult population skips care due to out-of-pocket costs each year and thousands of people die for want of insurance or treatment.
THE PROGRESSIVELY PROGRESSIVE PROGRESS NARRATIVE: Vice President Harris’s health care agenda relies on a narrative of progress toward securing “affordable health care” as “a right” under current and past Democratic leadership.
As Healing and Stealing predicted in March, the Biden/Harris Administration and the national Democratic Party have stimulated a tsunami of fake good news on the subject. A quick reminder of the relevant facts:
The percentage of U.S. adults who were covered all year with health insurance and also not underinsured grew from 56% in 2010, when the ACA passed, to 57% in 2022, according Commonwealth Fund surveys. At 1% improvement every 12 years, U.S. adults will be able to get the health care they need without worrying about bankruptcy in about 5 centuries.
Those surveys suggest that even a 500-year pace may overestimate the rate of U.S. progress. The percentage of non-elderly U.S. adults who skipped needed health care due to out of pocket costs actually increased from 2010 to 2022.
Sustaining the progress narrative requires a comically dishonest presentation of “facts.” Harris’s materials include the claim that the ACA’s cost-savings and Biden/Harris policies are “driving the lowest uninsured rate in American history.”
The sources for the claim are reports from the Census Bureau and the Centers for Disease Control and Prevention. The Census data are from February-April 2022, before Biden and Harris, at the direction of a Democratic Congress, started kicking 25 million people off of Medicaid. The CDC numbers are from surveys conducted throughout 2023, when the Great Medicaid Purge was still ramping up.*
The pandemic-era rules that kept people on Medicaid were passed by a Democratic congressional majority and signed into law by then-President Donald Trump in March 2020. After Trump’s defeat, the same Democratic Congress sent the repeal to Trump’s desk, which he signed. Biden and Harris then worked with states to boot 25 million Americans off of Medicaid.
Of course, having “insurance” also matters little if your out of pocket costs are so high you don’t get needed treatment. Since 2010, U.S. health policy has shifted millions of Americans from being uninsured to underinsured, making uninsurance an increasingly less signficant measure of medical financial distress.
What Harris Says She’ll Do [And What She’s Silent About]:
Harris has not commented on what would be the most consequential and controversial health care issue of her Presidency. Oregon and California recently passed state single-payer (OR) and “unified financing” (CA) laws to cover everyone in their states with comprehensive benefits and centralize financing. Both require groundbreaking waivers of federal health care statutes. Both states held off applying for those waivers until after Election Day so the Democratic candidate wouldn’t have to address them in the heat of the campaign.
The Secretary of Health and Human Services, the Administrator of the Center for Medicare and Medicaid Services (CMS) and Director of CMS’s Center for Medicare and Medicaid Innovation (CMMI) would likely be the key officials responsible for the federal response. No short list for these positions has surfaced, but Healing and Stealing couldn’t help noticing that Dr. Mark Ghaly, who as California Secretary of Health and Human Services oversaw the multi-year process that resulted in the state’s unified financing law, recently left state government. Otherwise, Vice President Harris says she will:
Make expanded ACA premium tax subsidies permanent
Create new Medicare vision, hearing and home care benefits
Negotiate more Medicare drug prices and cap out of pocket drug costs
Maintain the private insurance status quo through regulatory enforcement.
Encourage states, hospitals and other providers to forgive medical debt after patients have been tormented by collections for 18 months and the debt is worth pennies on the dollar.
Defend abortion rights and prevent discrimination against lgbtq+ patients
Fight the opioid crisis with the same tools as Trump - policing and border enforcement
1. Make expanded ACA premium tax subsidies permanent.
The 2021 American Rescue Plan Act temporarily increased federal tax subsidies to help people afford ACA exchange coverage and allowed people with incomes greater than 400% of the federal poverty level to receive some of the subsidies. The Inflation Reduction Act extended those improvements through the end of 2025. Harris wants to make the changes permanent.
ACA tax credit subsidies for premiums are capped at a percentage of subscribers’ income. The expanded subsidies reduced those caps, cutting the amount that people have to pay for premiums by an average of 44%, according to KFF Health News. For poorer families the cost of premiums for a “benchmark” plan on the exchange went to zero. As a result of the exit of 25 million people from Medicaid and the lower cost of ACA benchmark insurance coverage, enrollment in ACA plans reached a record high of 21.5 million this year.
Unfortunately the “benchmark” plan to which the subsidies apply doesn’t cover that much. ACA plans are assigned a metal - bronze, silver, gold, platinum - according to how much of the cost of health care the insurer actually covers. The ACA’s “benchmark” plan is the second-cheapest silver plan in each region.
Silver plans cover 70% of the expected cost of health care, leaving 30% to the “consumer.” Private insurers are allowed to impose deductibles, copays and coinsurance that add up to $9,450 a year for an individual and $18,900 for a family in silver plans, according to guidance from CMS. For people who earn between 200% and 250% of poverty, HHS reduced those maximums to $7,550 and $15,100 in 2024. For those between 100% and 200% of the federal policy level - that’s $15,060 - $30,120 in annual income for an individual, and $20,440 - $40,880 for a family of 2 - the limits are $3,150 and $6,300.
These numbers cast doubt on the both affordability and the “care” of Affordable Care Act coverage. According to the 2022 Commonwealth Fund surveys:
“[a]mong people who were insured all year in private health plans, …44 percent with individual market or marketplace coverage were underinsured.”
Commonwealth also found that 61% of all underinsured adults skipped needed health care in 2022. Preserving the expanded ACA subsidies is better than not doing so, but in no way transforms a failing health care system into a “right, not a privilege.”
2. Create new Medicare vision, hearing and home care benefits.
Harris has proposed three improvements to Medicare: hearing, vision and means-tested home care benefits. Currently, Medicare covers neither vision nor hearing, and long term care is generally funded through Medicaid payments for nursing home care.
Comprehensive Medicare hearing benefits would not only help people enrolled in Medicare, but help set an expectation for private coverage for everyone else. Researchers have found hearing loss may be associated with increased risk of depression, psychological distress, use of mental health medications and services, and dementia. Medicaid covers hearing loss in children and some state Medicaid programs cover low-income adults. Private health plans generally don’t and when they do, they usually offer discounts on hearing aids rather than actual benefits, according to Forbes interviews with audiology experts.
Some level of vision coverage is more common in private health plans, but like hearing benefits, conspicuously absent from traditional Medicare.
The Harris/Walz campaign’s announcement focused mainly on its proposed “Medicare at Home” benefit, which has strong support from unions fighting to expand home care funding and improve the abysmal working conditions in the industry. Service Employees International Union President April Verrett praised the plan in a statement issued when Harris announced the plan:
“Vice President Harris’s plan to provide a home care benefit through Medicare is a game-changer for working families who have been demanding a solution to the nation’s care crisis. It would provide tremendous relief to millions of families struggling to pay for care for aging seniors, giving them the peace of mind that their loved ones are safe and well attended in a setting that makes them the most comfortable.”
Medicare at Home will change games only if it avoids the onerous cost-sharing and perverse coporate incentives in the rest of Medicare. Given Congress’s unwillingness to addres those problems, the new benefit will lilkely fall short of its promise. The few details available from the Harris/Walz campaign’s October 8 “Fact Sheet” suggest a program plagued by the typical failures of American health care: means-testing; high out of pocket costs; maddening bureaucratic complexity and; the usual opportunities for massive corporate looting, perhaps not surprising given the proposal’s origins.
The Harris/Walz campaign relied on two recent proposals by researchers from Georgetown University and Brookings authored by seven prominent Democratic Party experts. Brookings Visiting Fellow Wendell Primus was former House Speaker Nancy Pelosi’s top health care staffer for 18 years and “the lead House staffer in developing the Affordable Care Act.” His co-author Jonathan Gruber was a key ACA advisor to President Obama, who famously admitted that he and Obama sold the so-called “Cadillac Tax” with rank lies. Here are the issues to watch out for should Harris win the election and move legislation.
Limited Benefits: The Fact Sheet implies - but doesn’t specify - that benefits may be capped to 20 hours per week: “the vast majority of seniors with long-term care needs are still able to live in their homes with an average of 20 hours or less a week of care provided by a home care aide for daily activities such as bathing, eating, and cleaning.”
Means Testing and Cost-Sharing: Medicare at Home will provide “coverage for those of modest incomes with a sliding scale for cost-sharing for seniors with higher incomes.” Brookings starts its verson of “higher incomes” at just 150% of poverty with assets of $30,000.
People who require home care to meet daily living needs often also require significant care from physicians and hospitals. With traditional Medicare enrollees responsible for more than $3,800 in premiums and deductibles for hospital and physician care before their insurance kicks in and 20% of everything when it does. On top of that, most Medicare patients face another $590 in drug benefit premiums and up to $2,000 in out-of-pocket prescription costs. More cost-sharing could turn any relief Medicare at Home offers families seeking to treat loved ones at home into another source of medical debt.
Corporate Looting: The campaign’s Fact Sheet strongly hints that Medicare at Home will be administered through the same private insurers who currently run Medicare Advantage (“MA”) and Part D drug coverage plans. The campaign promises to “innovate and engage with the private sector,” and “draw upon best practices across Medicare plans…”
The potential for corporate looting is powerful.
For example, Medicare at Home benefits are supposed to start with having enrollees “independently evaluated by physicians or nurses” for their home care needs, but the Fact Sheet doesn’t say who will employ the nurses and doctors. Medicare is awash in an “upcoding” scandal that may have cost the government as much as $12 billion in unnecessary payments in recent years as a result of exactly these types of in-home assessments of patients.
A Health Affairs analysis by Brown Univeristy researchers found that in-person in-home Health Risk Assessments tended to increase the risk scores that Medicare uses to determine how much they pay different MA insurers for premiums. HRAs conducted by company providers tended to find new diagnoses for patients, and the resulting “escalating coding intensity” - a marvelous academic euphemism for suspected systematic lying - may have resulted in overpayments totalling between $4.5–$12.3 billion.
According to the Commonwealth surveys, 38% of Medicare beneficiaries skipped needed treatment due to cost in 2022. New hearing, vision and home care coverage could potentially help pay for critically needed care, but layering more means-testing and cost-sharing on top of an already tattered program will dramatically reduce the security Harris’s new benefits promise.
3. Negotiate Medicare Drug Prices and Cap Out of Pocket Drug Costs
The Biden/Harris Administration’s most heavily promoted health care successes involve prescription drugs - capping out of pocket costs for insulin products in Medicare at $35/month; capping total out of pocket pharmaceutical costs in Medicare at $2,000 per year per person, and; negotiating lower prices for 10 Medicare drugs. Congress and the Administration also began penalizing the manufacturers of some drugs sold to Medicare if their prices grow faster than inflation. Harris has promised to extend the two out of pocket limits to everyone with private insurance and to “accelerate the speed” of Medicare price negotiations.
Medicare price negotiation is a rare 21st century reform that moves the U.S. toward treating health care as a public good. Governments of countries with universal health care systems all over the world regulate how prices are set to ensure that people get the medicine they need without bankrupting themselves or their countries. Federally negotiated drug pricing is an essential element of proposals for improved, fully-funded Medicare for All. There are two key problems with Biden and Harris’s approach.
First, the pace of negotiations has been glacial (although the Administration moved faster to start charging drug companies rebates if their prices grow faster than inflation). Biden scrapped a hastily constructed but more ambitious approach initiated by Trump and started from scratch. Prices for the first 10 drugs do not go into effect for 15 months and the law permitting the bargaining must survive industry lawsuits.
Second, neither Harris nor her surrogates have bothered to ask the obvious question: what exactly does the private insurance industry do with the $117.3 billion in premiums and other payments Medicare and the millions of people enrolled in the program spend on them every year?
Private insurers bank billions of dollars in public money every year but don’t do their core job: negotiate reasonable drug prices for us. The federal government is starting to do it for them but still showers private insurers with cash and forces seniors who want prescription drug coverage to sign up for the private plans that can’t or won’t do their job. This is typical of 21st century U.S. health care policy, as we saw with the No Surprises Act, which created a federal arbitration system to resolve complaints about out of network claims that are at the heart of current insurance market structure because the insurance companies couldn’t or wouldn’t.
In the end, however, no matter how slowly it’s started, the federal government should negotiate drug prices. By contrast, the $420 per year (12 x $35) insulin out-of-pocket cap and $2,000 overall prescription cap are short term gimmicks.
For Medicare patients, the $2,000 out-of-pocket cap is for pharmaceutical coverage only, and doesn’t go into effect until January 2025. The current out-of-pocket cap is set at $3,500. These pharmacy costs are layered on top of the premiums and out of pocket costs for the rest of Medicare described above. The Medicare Payment Advisory Committee expects that the Part D deductible - just for prescription drugs - will be $590 next year.
Capping out-of-pocket insulin payments (and exempting insulin products from the deductible) may help some people who can afford $420 a year. But when applied to private insurance (and in Medicare too), both of these out of pocket “caps” will simply shift costs from patient spending at the pharmacy to premium prices, until policymakers take control of drug prices and evict the health insurance industry from its perch in control of health care spending.
According to the 2024 KFF employer survey, from 2020 to 2024, premiums for employer-sponsored family health insurance increased by $4,230 (20%) with workers’ share growing by an average of $708, continuing a spiral that costs workers thousands of dollars each year (for the KFF data, see figure 6.5).
4. Maintain the Private Health Insurance Status Quo
If Harris wins, voters should expect plenty of scolding of select health care corporate wrongdoers, and various attempts at piecemeal regulation of normal market phenomena like facility fees. In language similar to Trump and Project 2025, Harris promises to improve health care through transparency and competition. She apparently intends to start with the latest villain du jour - pharmacy benefits managers.
In the early decades of commercial health insurance, prescription drugs either were a small portion of health care costs. PBMs developed in the late 1960s as drug costs grew. Without formally taking on insurance risk, PBMs negotiated prices for networks of suppliers and retailers, set up approved lists of drugs and managed patient benefits, allowing insurers to offer optional drug benefit packages to employers.
The once-independent PBMs were long ago bought by the big insurers and drug store chains, which makes Harris vaguely referring to PBMs as ominous “pharmaceutical middlemen” political performance art barely worthy of dinner theater.
The FTC sued the three largest PBMs that managed Medicare benefits last month for illegally inflating insulin prices. Optum RX, Express Scripts and Caremark Rx control 80% of pharmacy benefit market. They aren’t random, mysterious “middlement,” they’re divisions of the two largest private Medicare health insurers in the U.S., UnitedHealth Group and CVS Health and a third major insurer, Cigna. CVS is simultaneously also the largest U.S. retail drug store chain.
The parent companies are no strangers to government scrutiny. Two weeks ago Senator Richard Blumenthal (D-CT), Chair of the Permanent Subcommittee on Investigations of the U.S. Senate’s Homeland Security and Government Affairs Committee, issued a staff report criticizing United, CVS and another Medicare insurer, Humana, for denying prior authorization for rehabilitative care after patients are treated in a hospital “at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for Medicare Advantage beneficiaries.”
UnitedHealth, CVS, Cigna and Humana earn billions of dollars running Medicare Advantage health plans and Medicare Part D drug coverage for seniors. They are the same private sector “Medicare plans” with whom a potential Harris-Walz administration plans to “innovate and engage,” to “draw upon” their “best practices” for Medicare at Home, vision and hearing benefits.
The Subcommittee report focuses on the use of artificial intelligence algorithms to deny claims. As Healing and Stealing reported in January, the HHS inspector general has been finding private Medicare insurers making abusive prior authorization decisions since at least 2007, whether abetted by AI or not. Although Blumenthal’s report at least mentions the fact that Medicare Advantage costs the federal government much more than traditional Medicare, it merely recommends that CMS collect more detailed data and conduct individual company audits, for a deadly problem that is 17 years old.
The report also calls for additional regulation of insurers’ internal utilization management committees, which would be funny if the outcome didn’t kill and injure thousands of people. The entire broken private “managed care” insurance structure rests on the absurd idea that profit-extracting insurance companies should and can have “independent” internal clinical committees that render honest judgments about patients’ needs.
In contrast to negotiating pharmaceutical prices, the regulations called for in the report - and dozens of other attempts to regulate things like facility fees or hospital charity care - are not incremental improvements to our health care system. They are fuel for the national Democratic Party’s progress narrative, part of an eternal cycle of pretending that, as Sen. Blumenthal concludes, “there is a role for the free market to improve the delivery of healthcare to America’s seniors.”
5. Take Feel-Good Action on Medical Debt
In 2019, then-Senator Kamala Harris briefly dallied with improved and expanded Medicare for All, which would cover everyone in the U.S. with no cost sharing and turn medical debt into a horror story from the distant past. Having abandoned the pretense of supporting universal coverage, as Vice President Harris jumped on the medical debt relief bandagon.
Healing and Stealing has covered medical debt, the distorted media coverage of it and 20 years of failed state regulations in detail (original FAIR story here).
For new readers, “smart, measured actions” means waiting at least 18 months while hospital (and physician office) bill collectors harass patients, sometimes with lawsuits, wage garnishments, liens on homes and bank account seizures. At that point, the hospitals - most of them multi-billion dollar corporations who don’t pay taxes - write the debt off and sell it for pennies on the bill’s face value to third party collections corporations who profit by continuing to torture patients.
State and local governments and private organizations have used public and foundation money to buy up and retire some of these older debts, usually by working with the non-profit RIP Medical Debt. This process doesn’t “end medical debt” as campaign surrogates claim. Uninsured and underinsured people continue to accumulate billions of dollars in unaffordable bills, and state level regulations have failed for 20 years to address it.
The only major medical debt development since Healing and Stealing’s article is a study by Stanford researchers working with RIP Medical Debt. They found that medical debt relief causes only a “moderate reduction in …payment of existing medical bills.” More importantly, on average, debt forgiveness has “no impact” on families’ overall financial distress** (full cite at “A Little Extra for the Data Curious”)
Medical debt relief is another example of health care status quo preservation: ineffective, feel good, media-friendly policy that makes no one with power uncomfortable and doesn’t take a single step in the direction of universal comprehensive health care or cost control.
6. Defend abortion rights and prevent discrimination against lgbtq+ patients
While former President Donald Trump struggles to navigate the tension between anti-abortion activists and public support for abortion access, Vice President Kamala Harris has fully embraced reproductive rights. Harris’s long-held personal views coincide with one of Democratic voters’ most urgent concerns.
The Vice President is so eager to campaign against a national abortion ban that she keeps insisting Trump supports one even though he has said repeatedly he doesn’t and would veto a national ban. By insisting that Trump’s views are identical to Project 2025, Harris has gifted herself the luxury of campaigning against something that her opponent doesn’t support on an issue of great public concern.
Harris says she will sign a reproductive freedom bill if Congress sends her one and veto any national abortion ban.
She has also committed to signing the Equality Act, which would add prohibitions on discrimination based on sexual orientation and gender identity to the nation’s core civil rights laws. Current Supreme Court precedent prohibits discrimination based on sexual orientation, but the Equality Act would enshrine them clearly in law. Congress passed and Biden signed protections for same-sex marriage in 2022, while the broader Equality Act passed the House but died in the Senate Judiciary Committee. Under the current Republican House majority, the bill hasn’t moved.
The Equality Act’s protections apply broadly, but health care has always been and remains an important policy battleground for lgbtq+ rights. Trump relies heavily on virulent anti-trans rhetoric, and among other things he has promised to revoke a Biden/Harris Administration interpretation that the ACA’s anti-discrimination language shields gender-affirming health care from state regulation.
Pending the outcome of the election, it’s impossible to predict whether Congress will send a national abortion ban, a reproductive freedom bill or the Equality Act to the White House in the next four years. Should that happen, there is no reason to believe Harris would not follow through on her promises.
7. Fight the Opioid Crisis with Policing and Border Enforcement
Vice President Harris says she “has already helped to direct more than $160 billion to disrupt the flow of illicit drugs and stop record amounts of fentanyl from crossing our borders.” Consistent with her rightward turn on immigration, Harris promises to sign the bipartisan border bill that has languished this session to further increase border surveillance and “intercept even more illicit drugs.”
Under Biden and Harris the FDA made the overdose drug Naloxone an over-the-counter medication, a decision that likely saved thousands of lives. But beyond that, Harris’s positions on addictive disease are difficult to distinguish from Trump’s.
A LITTLE EXTRA FOR THE DATA CURIOUS
*”…before Biden and Harris, at the direction of a Democratic Congress, started kicking 25 million people off of Medicaid.” The Census report “presents statistics on health insurance coverage in the United States in 2022 and changes in health insurance coverage rates between 2021 and 2022. The statistics in this report are based on information collected by the Current Population Survey Annual Social and Economic Supplement (CPS ASEC).” The CDC report is based on the 2023 National Health Interview Survey. The report says that NHIS conducts surveys throughout the year. The Great Medicaid Purge did not begin until April, 2023 and ended in September 2024.
**Raymond Kluender, Neale Mahoney, Francis Wong & Wesley Yin, “The Effects of Medical Debt Relief: Evidence from Two Randomized Experiments”, NBER Working Paper 32315, DOI 10.3386/w32315. Issue Date: April, 2024.