What about Medicare for All?

In the past few months, there  has been a lot of talk by Democratic candidates for President about Medicare for All and single payer health plans .  With Medicare Open Enrollment looming this week, along with the Democratic debates in  November,  I thought it might be helpful to review the pros and cons of Medicare for All. Let me start by saying we badly need reform of our health”non” system.  However, how fast should we push reform and what are our goals? I believe there are three priority goals: we need to figure out a way to cover everyone, implement more coordinated quality care, and  control the costs that make the U.S. unique in the world for paying more than any other country.

Understanding what Single Payer means

The two most sweeping proposals for reform are from Senators Bernie Sanders and Elizabeth Warren. Although many fervent single payer advocates support what Senator Sanders is proposing, some of his newest followers may not realize what his proposal would mean in practical terms. To start with, what does the term single payer really mean?  While polls show a surprising amount of support around the country for single payer health care, the definition of single payer remains opaque and confusing to the public. To some, it simply means getting rid of private for-profit insurance companies; to others it means public financing of health care; and still others, free care. But the term “single payer” usually refers to the method of collecting revenue, usually by the government through taxation, to pay for and administer health care services for a specific population. Our own program for the elderly, Medicare, uses a single payer financing approach. But while Medicare uses our tax money to pay for health care for people over 65, it contracts with private insurance companies and private providers to actually deliver the care. Sanders’ plan promises a supplemental role for private insurance but only for services like cosmetic surgery that Medicare does not cover. This makes Medicare quite different from the British health care system, where most providers actually work for the government, and supplemental plans are a small part of the overall system.

The fact that Medicare continues to rely on private health insurance plans is something that many supporters of single payer find objectionable. After all, much of the dissatisfaction with the Affordable Care Act (ACA) has been the  reliance on private health insurance companies to offer coverage through the state exchanges, and the fact that, for many, health care costs continue to be a significant burden.

Simplicity is attractive

The simplicity of Medicare for All is what makes it so attractive, given the complexity of our current system. Under Sanders’ Medicare for All everyone gets an insurance card – even undocumented immigrants. There are no copays or deductibles. Just take your card to the doctor or hospital of your choice and it will be accepted. All care would be included, e.g.hospital, primary care, mental health, vision, hearing, long-term care, prescription drugs. The federal government would roll the financing of all existing public programs (Medicare, Medicaid, Children’s Health Insurance Program, etc.), into a single integrated system administered at the national level. Savings would come from the elimination of the administrative costs and high salaries of private insurance companies.

Senator Elizabeth Warren has supported Sanders’ Medicare for All, but with relatively few details about how she would implement it. In fact, it’s a little difficult to find her plan on her website.  This is what she says about it, and it’s not very detailed about cost. Other candidates have been pressing her on whether or not the middle class would pay more in taxes under her plan. While she consistently claims “costs” would go down, she does not say whether taxes for the middle class would go up.

Both Sanders and Warren have said they do not want to completely get rid of the ACA, and certainly not right away. But if their programs were nationally administered, it is not clear what role the state exchanges would have or what would happen to the Essential Benefits outlined in the ACA. It seems that the choice of plan would be replaced with free choice of doctor or hospital. However, as disruptive as the destruction of private insurance would be, Sanders also proposes eliminating all employer-sponsored health insurance plans as well. While some employers might welcome getting rid of the burden of providing health insurance, most still oppose the idea, and unions are leery as well.

Some burning questions

Several big questions remain: What would Medicare for All cost, would it improve quality of care,  and is there political support for doing it?

Many economists are extremely skeptical about the costs. A single payer plan requires the American public to trade the costs they currently have (e.g. monthly premiums, copays, deductibles, and for Medicare itself, payroll taxes) for a simpler up-front tax which Sanders and Warren claim would be cheaper in the long run for most Americans. The plan also relies heavily on being able to save costs in the medical care system to make up for what taxes cannot raise, but that likely means paying providers less —not a popular option, potentially causing some providers to refuse to participate in the Medicare program.

The biggest flaw in the Medicare for All plans may be a lack of clarity about how costs would be controlled. With a large increase in demand for services, we would also have to increase the number of providers dramatically, which would not happen over night. To provide “free” care to all who want it, would require a lot of “under the counter” rules about how much health care any person could get, to avoid the potential of fraud by providers and of people using too much unnecessary care. There would also undoubtedly  be visible tax increases for some Americans.

Would Medicare for All improve the quality of care you receive? That’s a harder question to answer, because quality is a vague term and very much in the eye of the beholder. For a patient, quality might mean having a real person answer the phone when you call; having access to a variety of providers who would coordinate your care; or  not having to worry about the cost when you are sick. There is plenty of room in our current system for improvement in all of these areas, but implementing Medicare for All might or might not deliver better quality. Still,  it’s important to remember that “more” health care services do not equate to “better” services. We already know that much of what medicine provides is not proven and can even be harmful. Simply offering free care to everyone is not an assurance that the care would be high quality.

As for the politics of all of this, the opposition among those who would have to vote for single payer is overwhelming. The ACA barely passed in 2009, even with a Democratic majority in the House and Senate. Now the Republicans have the majority in the Senate and it’s not clear that will change in 2020. Democrats might win a few more seats in the Senate, but their majority would still be a slim one. In what universe could a President Bernie Sanders or Elizabeth Warren  pass a massive federal takeover of the financing of health care (and this time it really would be a takeover) in this divided political environment?

If implementing Medicare for All seems nearly impossible politically, is all hope lost for a more publicly accountable and affordable health care system? Maybe not. Are there any suggestions for how we might move ahead? So far Sanders has not suggested any incremental approaches and while some candidates defend  the ACA, they have not been very explicit about it either. The failed attempt to implement a national plan by the Clintons looms large over the politics of today.

Several candidates suggest bringing  back the idea of a Public Option as a plan choice within the state exchanges as one way to demonstrate the feasibility of a publicly administered approach. Joe Biden strongly supports a public option, as does Mayor Pete Buttigieg.  Other candidates talk about expanding Medicare access to people over 50, since buying health insurance is very expensive for the 50 to 65 year old age group.

The big problem with health care reform has always been that it is  extremely complex, and improvement for some means take-aways for others. Those who would lose under a single payer plan in America include many physicians and hospitals who would be paid less, and a severe retraction in the health insurance and pharmaceutical sectors. The winners might be the American public, many of whom would gain access to care that they were not able to afford before, the simplicity of a single payer system, and the potential for real savings by eliminating much of the administrative costs of private insurance.

It remains shameful that we do not guarantee “health care for all” in our country.  Would Medicare for All provide the solution? As the health care debate goes forward, it is important to ask the candidates to provide specifics about how such sweeping change would really work — and how much it would cost. It certainly won’t be free.