Reforming Medicare to get to Single Payer.

[Meldread]

One of the goals I am pretty sure most people here share is to see single payer healthcare in the United States. The real question is how do we get there from where we currently stand?

My thinking was that it would make sense to reform Medicare so it would look more like a single payer system. Then begin folding in the various other government run healthcare systems, such as Medicaid, SCHIP, and Veterans Healthcare (Medicare with specific benefits to Veterans). Then begin folding in all government workers who are on private insurance into the program as well. Basically, we would be taking Medicare and folding in all currently government funded healthcare into a single payer system.

This accomplishes three things. First, it gets us a step closer to single payer. We now have a framework that we can eventually expand to include others. Second, it would ideally cost LESS than the current system, making Medicare overall more stable. Third, it would provide greater political protection to those on the program. One of the big issues with programs like Medicaid is that it's easy to attack since it is for poor people, but by lumping the poor with those old enough to be on Medicare--and thus more likely to be politically active and vote--that gives greater protection to the system against Republican attacks.

The next step would be to try and strengthen Medicare single payer, by opening it up as a public option on the ACA Marketplace. This would force private insurers to compete with the Medicare program, and open the door for us to gradually move it so that the Medicare program overtakes the marketplace, more-or-less pushing out all the competition. This more-or-less eliminates the taxation issue, as people would be "buying" health insurance, and it would make Medicare more financially sound, since most people buying into it will be middle aged or younger.

This could be combined with various incentives for businesses to shift from the private health plans to the public Medicare plan. There could also be incentives provided to states, in an effort to entirely federalize Medicare, allowing us to get around the stupid SCOTUS rulings that allowed states to reject Medicaid expansion. By federalizing everything, we basically take states out of the equation, and can ensure that EVERYONE has access to healthcare.

Over a decade or so, I think we could eventually nudge the country toward a more-or-less defacto single payer system.

What are peoples thoughts on this method of getting to single payer?

[virgogal]

1. I'm on Medicare now but I don't understand your fourth paragraph.

Could you clarify it a bit?

[Meldread]

6. Sure, here is what I meant.

We fought for the public option to originally be part of the ACA and failed. That doesn't mean we can't go back and try again in the future. One of the critiques at the time was that the public option would eventually overtake the marketplace (private insurance can't compete), and open the door to a single payer system. This was one of the reasons some people were against it.

I'm basically saying, "Yeah, exactly. Let's make that happen."

One of the big issues that always faces a program like Medicare is that, because those on it are older and need more healthcare, the costs are much higher. The way traditional insurance balances this out is by having younger and healthier people pay into the system, since they use healthcare less. So, when I talk about stabilizing Medicare financially by allowing people to buy into it via the marketplace, it means that the majority of people buying into it would be younger and healthier. They would also be "buying" insurance that would be much cheaper than private insurance. This money would then allow them to get on Medicare, and also help ensure that it remains adequately funded.

I am not talking about disrupting current methods of funding for Medicare or Medicaid, except where necessary to federalize the programs and take them away from the states (thanks to the SCOTUS ruling regarding Medicaid expansion).

Does that make more sense?

[virgogal]

10. It certainly does make sense.Thank you very much.

[leftstreet]

2. OMG a Public Option?! Why didn't anyone think of that?

President Barack Obama promoted the idea of the public option while running for election in 2008.[3] Following his election, Obama downplayed the need for a public health insurance option, including calling it a "sliver" of health care reform,[4] but still campaigned for the option up until the health care reform was passed.[5]

https://en.wikipedia.org/wiki/Public_health_insurance_option

[Hoyt]

3. There's a lot to be said for that. I think a Public Option is the best way forward.

It keeps us from having to fight for legislation that puts everyone under a Medicare For All type system. According to polls I've seen, over 40% of people are against single payer. But if they can initially keep their "preferred plan", many would gravitate over time to a public option (assuming it delivers). I believe a fight to put everyone under single payer will result in GOPers repealing ACA and giving everyone inadequate vouchers.

[Sgent]

4. Medicare

comes up short in a lot of ways.

Most people would have worse insurance if all they had was Medicare (unlimited out of pocket, etc.).

[Meldread]

7. That's why I am talking about reforming it as well.

I am basically talking about reforming Medicare so that it looks more like a single payer healthcare system, and folding the other government plans into it. My hope is that if this were structured properly, it would either cost as much as the current system (factoring in all the current government spending on healthcare) or hopefully at least slightly less.

If we could improve the system AND make it in some ways cheaper, then we can make the argument that not only are we providing better healthcare, but we are also being fiscally responsible on top of it all. I am not sure if this is possible, of course, it may end up costing more. In which case the argument should be that we are fighting to improve Medicare for seniors, and highlight the benefits that they would receive.

[SickOfTheOnePct]

9. It won't cost the government less

once you pull in all of the FEBP (Federal Employee Benefit Plans).

[Meldread]

11. Here is something like what I am envisioning...

I am thinking of something along the lines of using Medicare reform as a basis for laying the foundation for a European-style single payer system. Here is how I imagine things would look once it is fully implemented:

Core Aspects of the Plan
1. Most individuals will have two health plans, the basic plan and a supplemental plan. The basic plan, which is what Medicare would be restructured into, would cover all the basic and necessary aspects of healthcare. Beyond the basic plan, an individual can choose to purchase additional supplemental health insurance coverage. (This is how most European single payer systems work.)

2. All healthcare purchases are made through the healthcare.gov marketplace. This includes getting access to medicare and supplemental insurance. This allows price and plan comparison.

3. A restructured single payer style Medicare plan will serve as the basic foundation for health coverage. An individual can choose to "buy" into Medicare or purchase private insurance. Private insurance can compete with Medicare, but ALL plans must offer the same basic coverage that Medicare offers at a minimum. Private insurance can, of course, offer greater basic coverage. All supplemental insurance is private, just like in many European countries.

4. All healthcare providers will be required by law to accept Medicare, and everyone is eligible for Medicare coverage should they choose it as their basic option. (This is also the default option.) The government AND private insurance companies will collectively bargain together for competitive prices from health providers, and private insurers may collectively bargain together with providers for additional coverage beyond what the government covers. Providers are not required to cover anything in private plans beyond the basic coverage collectively bargained with the government, nor are private insurers required to provide their purchasers access to ALL healthcare providers.

5. Plans will be financed through a combination of tax payments (largely payroll taxes), wealth and income adjusted purchases from the marketplace, and co-payments.

6. All individuals will be assessed based on wealth, income, and health liability. This will automatically be done by signing up to the marketplace. Based on these assessments and the overall cost of the medicare program the government will offer a subsidy. All Americans will receive a flat subsidy based on those factors, balanced against the cost of the medicare program, with the goal of making medicare cost $0 for most Americans (they will be completely subsidized). Beyond that, those with high wealth and high income will go beyond what the subsidy allows and will begin to have to pay some out of pocket. After a certain wealth and income metric, a progressive Value Added Tax will be added to healthcare purchases to further help subsidize low wealth and low income individuals. If an individual chooses a non-medicare plan for basic coverage, they will only receive 80% of their subsidy.

7. The government will bee required to project healthcare costs, and have both the payroll, VAT, and co-payments adjusted according to rising healthcare costs with certain caps in place to prevent excessive taxation.

8. The system should find ways to both reward and discourage bad healthcare behavior on the part of both patients and providers. HHS will be in charge of setting those rewards and discouragements and the overall oversight and management of Medicare and the system as a whole.

Just to be clear, we are talking about a single universal plan being offered to all people. This core plan would be Medicare, and private insurance companies can compete against it in the marketplace (like they would any public option). However, they would be required to offer the same base plan as well, with the potential for additional coverage. All Americans will receive a subsidy which should cover 100% of the cost of the medicare program for most Americans (they actually pay some via payroll taxes). If an individual chooses to purchase a non-medicare program with their subsidy they will only receive 80% of it. Wealthier Americans will help subsidize poorer Americans by paying some of their healthcare coverage out of pocket. Extremely wealthy Americans will begin paying a progressive VAT on their health insurance to help further subsidize lower income Americans. The system should largely be self-funding, as the taxes collected should be automatically adjusted without the need for Congressional oversight or tampering. However, there are caps in place to prevent excessive taxation, meaning there are limits to which the system can be pushed if poorly managed. To help in that management healthcare providers and patients will be incentivized through rewards and discouragements based on bad healthcare behavior that causes costs to rise. For additional healthcare beyond the basic medicare coverage, individuals will be able to purchase additional supplemental health insurance through the marketplace.

This is how I would imagine the system functioning.

[SickOfTheOnePct]

12. My preference would be true single payer

But with the ability to opt out of using it, but not to opt out of paying for it. So, take the taxes to pay for it, but if someone chooses to pay out of pocket rather than use the government plan, so be it.

And if Medicare is simply going to be a public option, then I'm not in favor of forcing doctors to accept it.

[Meldread]

13. That is how it more-or-less works in most European countries.

I think you may have to better define what you mean by "true single payer."

Here is how healthcare works in Switzerland:

Here is how healthcare works in France:

Here is how healthcare works in Canada:

Here is how healthcare works in England:

I like Aaron because he's a data driven guy. It helps keep the focus on the facts rather than feelings people might have over this or that system. As you can see, what I proposed is more-or-less what most people would regard as a single payer system. They, of course, vary greatly depending on the country and implementation. So it's hard to know what you mean by "true single payer."

What I was trying to accomplish is combine the various systems we currently have (including the ACA), and determine the best path to get us to a single payer system that is comparable to most European single payer systems. What I think I proposed does that. Is it perfect? Of course not. Like every single payer system, there are advantages and disadvantages. This is why these debates are always difficult and contentious.

I do not, however, think it is particularly harsh on providers. Just to be clear, I am saying that Medicare will be a government basic healthcare insurance program. All private plans would have to include all the things Medicare includes, though they may choose to go beyond what Medicare has in its plan. Providers are required to negotiate with the Government and Private Insurance companies over what is paid for their services, and they are required to accept ANYONE who has a health plan for their basic coverage. This isn't complicated, since regardless of your insurance provider, all the basic stuff covered by medicare will be identical regardless of your health insurance policy. However, providers are not required to accept insurance for things beyond what is covered in the basic Medicare plan.

Providers can collectively get together and bargain with the government on prices. This actually affords them greater freedom than under some other single payer systems in which the government simply sets a limit on what it will pay. This allows providers the freedom to argue for better payments, but it also allows for those offering the basic plan to bargain as well. In the end, they all must simply reach a deal, or no one can go to the provider. This does give huge leverage to the government and the insurance companies to force down costs, but it is still more freedom than in other single payer systems.

[SickOfTheOnePct]

14. True single payer is pretty easy

It's what Medicare is now - one payer, i.e., the government, pays the bills.

Under you plan, where Medicare is simply another option under the ACA, then no, I don't think providers should have to accept it, any more than they have to accept any other insurance.

[Meldread]

15. ...but why?

All the payments would be the same for everything Medicare covers, and the VAST majority of people probably upward of 80%, would have all their basic coverage covered by Medicare. The only people who would likely choose to have their basic insurance covered by private insurance would be those getting a really good deal via their employer or union, who have negotiated rates and perhaps specialized supplemental insurance to go along with it. They would be some hardcore cadillac plans, and they would lose 20% of their subsidies by choosing another provider that is not Medicare.

The basic care payments, those provided by Medicare, would still all be identical in price. So, I am unsure as to why they shouldn't deal with other insurers? Is it because of overhead cost? If so, that is easy to fix, you simply have Medicare make all the payments to providers for basic insurance that it covers, and have the private insurance companies reimburse the government. That's probably the easiest way to handle it anyway.

[SickOfTheOnePct]

16. It makes zero sense

To have a public option and private insurance that has all the same coverages and all the same payouts. If that's the case, then just go to single payer, because if they're all the same, there is no real choice anyway.

And the idea of the government paying the bill and then reimbursing the insurance companies is just adding an extra, unnecessary step that adds more cost.

[Meldread]

17. In order to do that...

...you would have to eliminate the market place and basically do away with the ACA. You wouldn't be able to get a foot in the door toward single payer, because the clearest path is offering some form of a public option.

However, let me address the two points you made.

1. It's true that there is no real choice in terms of basic health coverage. Health insurance companies can't compete by just offering basic health coverage alone, they have to offer additional coverage that goes BEYOND the basic coverage. In short, they'll have to start offering some supplemental coverage along with basic coverage.

This is how most single payer systems work. They have a standard for basic coverage, and then they have the option for individuals to purchase private insurance for supplemental coverage not covered under the basic coverage. The goal, of course, is to more or less use the public option the way its opponents feared--to basically force out private insurance companies in terms of offering basic coverage so that we get down to a single payer system like you describe. That's why the system looks the way that it does, and why the vast majority of people are going to be on Medicare rather than private insurance.

Of course, you can be on Medicare and still by supplemental insurance. Alternatively, your employer or union might have negotiated a sweet deal for you with a private insurance company (this is where people most likely end up with basic + supplemental private insurance). Or you simply might be massively wealthy, and want the grand daddy of all cadillac plans. I say these things are fine, because in the end it is going to reduce overall costs. Not only are they losing 20% of their subsidy, they are also likely making enough money to start paying some of the VAT.

2. Regarding reimbursement it depends on how you look at it. You can either centralize the process of dealing with insurance companies in a single place (with the government), or you can force overhead onto providers, requiring them to work with multiple different insurance companies to get payment. What I proposed takes some burden off of providers, as they only need to interact with the Medicare system to get their payments, which can be streamlined and mostly automated.

Meanwhile, if we work the more traditional way, not requiring providers to accept all basic insurance coverage, then it means a few things. First, it means that individuals may be limited in where they go to seek care. It means that you may not get access to the best or most qualified doctors. You would only have access to doctors in your providers network. Second, it means that providers will need to negotiate individually with each insurance company in addition to the government on pricing. Providers will then be responsible for all the overhead necessary in collecting the payment dealing with multiple different payment systems.

It may, indeed, add an unnecessary step for the Medicare system, but it won't cost Medicare anything to do it, since the insurance companies would be required to reimburse them the total costs. (They could also charge the insurance companies a processing fee.)

[SickOfTheOnePct]

18. For some reason, you're

insistent on making this much, much more complicated than it needs to be.

A good first step would be to make Medicare the public option on the exchanges. That's it. No need to do anything with private insurers at all - just make Medicare the public option. The prices will be lower than other options, so more people will choose it. As they do, the other policies will continue to go up in price, because more people will go to the public option. As the prices on private policies go up, even more people will choose the public option. Eventually, there will be nothing left on the exchanges except for Medicare, and voila! we have single payer.

[Meldread]

19. The problem with that is...

...the problem with that is Medicare, as it currently stands, is not really designed for people to buy into it like that. In order to actually get Medicare where it's suitable to do something like that, you still have to reform Medicare first. Additionally, if you are offering it as part of the marketplace, you might as well reform Medicaid and the marketplace subsidies while you are at it.

You can't just throw Medicare as is on the healthcare marketplace. Especially considering Medicare is much more complicated and unnecessarily convoluted. You've got Part A, Part B, Part C, Part D, and Medigap. That doesn't even mention the issues with assignment as well, meaning that if more people get in Medicare there is very likely to be a lot of providers who simply stop accepting Medicare patients all together. They aren't going to want to eat that extra cost, which is more-or-less just passed onto those currently on the private market through private insurance. Of course, with less private insurance there are going to be fewer individuals to eat that cost.

Additionally, Medicare doesn't obviously deal with people who are pregnant and children. So there will need to be changes made simply to take that into consideration.

See where I am going here? This doesn't really fit with how the healthcare marketplace works. Medicare has to be reformed before it is offered as a public option. That's why I started there with my original premise, because I was heading down the same mental path as you.

[SickOfTheOnePct]

20. Yes

You would make Medicare cover all the stuff that the ACA requires of all policies, and then roll all of the parts together.

The assignment issue for Medicare is no different than any other insurance policy I've seen - assignment is nothing more than networks.

The problem I have with your plan is that you force doctors to accept Medicare from the exchange. Until we are actually at single payer, I don't see why doctors should be forced to accept Medicare when they aren't forced to accept any other insurance policy.

[Meldread]

21. Ah, okay.

Well, at least we are in agreement with the need to reform Medicare to make it work. So, we'll table that issue.

Technically speaking, providers aren't "forced" to accept Medicare. They could refuse to negotiate with the government, and instead negotiate only with a handful of private insurance companies. You could technically have a group of doctors who only serve a select few patients on some very specific private healthcare policies. There is nothing technically wrong with that.

The problem with doing that from the standpoint of a provider, however, is that you would no longer be seeing patients from the general public. In other words, the system HAS transitioned to a "truly single payer system" (using your phrasing), in that we have universal coverage and that everyone has "purchased" (most have been fully subsidized) a plan from the market place. Most people have selected Medicare, because the system is designed to nudge people onto the public plan.

The method that you are discussing will end up in a very similar place very quickly. You may cut out the collective bargaining between Medicare and the private insurance companies, meaning everyone gets different prices when they get healthcare providers. However, if your method is effective the government is more or less going to put private insurance companies out of business as it relates to basic medical coverage. This means that if they are not negotiating with the government, very quickly they are only going to be seeing a select few patients who have decided to stay on private plans for basic coverage.

So, in essence, we end up in the same place. If providers want to see patients from the general public, they will be required or forced to accept Medicare. This is true even if there are still technically private insurance companies on the market.

What I was trying to do is create collective bargaining on the part of insurance companies and the government, to ensure an equal access to healthcare providers across the board. By lumping the government and private insurance companies together, it would be my hope that they are able to collectively drive prices down. This makes basic coverage non-competitive since everyone is paying the same to all providers.

Of course, there is nothing that would say that a provider MUST accept basic coverage. They could, as I said, simply refuse to negotiate or only elect to negotiate with a select few private insurance companies. However, it is hard to imagine the benefits of doing that from the perspective of healthcare consumers. Not only would you be paying more out of pocket to get access to such a plan (losing 20% of your subsidy). You would also be limited to seeing a very small handful of providers at higher cost than everyone else. There really would be zero benefit to healthcare consumers to choose such a plan that I could imagine.

So, as I said, in the end when we are talking about being "forced" to accept Medicare, this is more of a consequence of how the market place would work with a public option. If virtually everyone is moving to get onto the public option, then it means that rather quickly if you don't accept it then you are no longer serving the general public. You would also likely be getting charged more to visit such a doctor if you had a private insurance plan.

In the end, regardless of which approach you use (mine or yours), the end result is the same: defacto requirements to accept Medicare if you are interested in serving the general public.

EDITED TO ADD: I should also point out that another reason I am pushing collective bargaining for Medicare coverage with providers, is because it prevents creating a system where the government is simply setting prices on how much it will pay. Thus, the government could say, "We are only going to pay $30 for an X-Ray." Providers have no say in this and simply must accept the price, and my concern is that is how your system would end up functioning to control costs. Once all the private insurers are 100% shut out of basic coverage, the government can simply set whatever prices it wants without any bargaining. This is bad for providers, who I also want to have the ability to collectively bargain.

My goal is to try and set fair but low prices through a collective bargaining effort between providers and insurers.

[SickOfTheOnePct]

22. Single payer and universal coverage are not the same

What you are describing is indeed universal coverage, but most definitely not single payer.

[Meldread]

23. I'm not sure that I agree.

Of course, all single payer systems offer universal coverage. However, it seems that your issue is that there is still a private market in existence. What I have proposed is a system somewhere between that of the Swiss and French system. Most people would regard them as single payer systems.

What system are you looking at as your model for single payer? Are you sure that you are advocating for a single payer system, rather than a fully socialized medicine system like the United Kingdom?

[SickOfTheOnePct]

24. France and Sweden are not single payer

There is nothing to agree or disagree about - universal healthcare and single payer healthcare are not the same thing.


Single payer means exactly that - single payer, i.e., the government. Having multiple payers, such as health insurance companies is most assuredly NOT single payer.

Thank you, but I know what I'm advocating for - single payer, like Canada has, not nationalized like the Great Britain has.

I'm confused as to why you would question what I'm advocating for when you obviously don't even understand the terms you're using.

[Meldread]

25. Private markets still exist in Canada.

There is obviously grey area between the terminology used between universal coverage, single payer, and socialized medicine. That is why I wanted you to provide a concrete example, so that we had a common basis on which to hold our discussion. I was starting to believe that you were envisioning a system similar to the U.K.

Now, we can focus on Canada. The Canadian system still has private markets and private insurance. While basic coverage is achieved through a Medicare like system, there are many services that are not covered, such as dental, optometry, and medications. There exists a supplemental healthcare system that is often offered as part of an employers health benefit package, and Canadians can purchase insurance packages from private insurance providers as well. Most of this, of course, is supplemental--covering things the government does not cover. Roughly 30% of healthcare spending in Canada comes from private spending, with roughly 70% coming from public spending. (Source.)

So, to drill down further and to be clear, are you saying that you want 100% of all health insurance provided by the government (thus no private supplemental systems allowed), or are you saying that there should only be basic health insurance provided by the government and supplemental insurance should cover the rest? What is your rational for favoring this type of system over others?

The reason I proposed the system that I did was that I was trying to avoid having the government simply set prices. One of the dirty little secrets in American health care discussions is that health insurance companies are not as powerful as many people think--it's one of the reasons that things cost so much more than other countries. Private insurers don't negotiate drug prices with Pfizer in Switzerland, for example. The Swiss government sets a price for drugs and lets Pfizer determine whether or not it wants to sell to Switzerland.

In the United States, insurers negotiate with hospitals and drug companies on their own, and they pay more as a result. Their negotiation power is so weak that they usually simply use what Medicare is paying as a baseline and then add a percentage on top of that. On average, for every $1 that Medicare spends on something, a private insurer is going to pay around $1.30.

The way I get around the government simply setting a baseline bottom payment, as we see in many other systems, is to create a system of collective bargaining. Private insurance companies cannot get better deals alone, and so they are strengthened against providers and drug companies by being able work together to set prices. However, the prices are negotiated rather than simply arbitrarily set.

One of the things that angers me is the fact that the United States essentially subsidizes other wealthy nations by paying so much for things like drugs and medical devices. One of the reasons drug and medical device companies are willing to accept so much less from other nations is because they know they can make up cost differences here in the United States. I am not interested in pushing the burden of paying for health care in the United States onto other nations, but I am similarly not interested in subsidizing other wealthy nations such as Canada and Switzerland. My hope is that through collective bargaining negotiations we can reach acceptable, affordable, and fair prices here in the United States. Then, ideally, private companies will then try and drive harder bargains with other nations--forcing them to pay more of their fair share. That will force their healthcare costs up, but it will hopefully drive ours down. By shutting out private insurance completely, my fear is that the incentive will simply to be to set prices as in other systems in order to control cost.

[SickOfTheOnePct]

26. No, there's really not a gray area

Universal coverage is an outcome. Single payer and socialized medicine is how it's paid for.

Canada has single payer - citizens can buy insurance, but only for things NOT covered by the government plan.
Great Britain has socialized medicine - the providers work for the British government.

[Meldread]

27. You really didn't answer my question or address my point.

I asked two questions.

1. Do you favor a private supplemental insurance market?
2. What is your rational for favoring this system over another?

Then the thrust of the main point for my position: The concern over arbitrary price setting by the government over negotiated prices.

[SickOfTheOnePct]

28. I've answered your question numerous times

I favor a single payer plan. The ONLY insurance that should be permitted is for "extras" not covered by the single payer plan.

[Meldread]

29. You've clarified your position, but...

You have said from the beginning that you favor single payer. We've established what you mean by that (you want a Canadian style system). I was curious as to whether or not you knew that the Canadian healthcare system had supplemental private insurance and the like involved. You've acknowledged that you knew, and you've clarified your position. We now know what you are advocating for, and we're both on the same page.

What you haven't done is explain WHY. That was my second question. You favor a Canadian system over a system similar to France and Switzerland. Why? Why do you think it is better? What benefits are there to one over the other? This is what I am trying to understand.

I've given the reason why I favor the system that I do. I can give additional reasons as well. I want to know why you favor a system similar to Canada.

[leftofcool]

5. Medicare as it is basically sucks.

It pays only 80%, does not pay for half of what it should for Seniors, you are forced into a supplemental plan and many doctors are moving away from taking it at all because it takes months to get the money from the government.

[Meldread]

8. As I said in a previous post, that's why I am talking about reforming it as well.

I am basically talking about reforming Medicare so that it looks more like a single payer healthcare system, and folding the other government plans into it. My hope is that if this were structured properly, it would either cost as much as the current system (factoring in all the current government spending on healthcare) or hopefully at least slightly less.

If we could improve the system AND make it in some ways cheaper, then we can make the argument that not only are we providing better healthcare, but we are also being fiscally responsible on top of it all. I am not sure if this is possible, of course, it may end up costing more. In which case the argument should be that we are fighting to improve Medicare for seniors, and highlight the benefits that they would receive.

[jwirr]

30. I like this idea. You spoke of the states - by federalizing in

the model of Medicare the administration costs would be cut a lot saving states and local counties a lot of money.

[Meldread]

31. Yes, exactly.

A major part of state budgets is how to deal with healthcare spending. By federalizing it we take the burden off of states, but we also standardize the system. We make it universal and uniform across the entire country. This should, hopefully, reduce its complexity.