Why Medicare-for-All is Not Enough

Doctors Prescribe Single-Payer Health Care Reform

Doctors Prescribe Single-Payer Health Care Reform

Dr. David Himmelstein speaks at a news conference about the new Physicians’ Proposal for Single-Payer Health Care on the steps of City Hall in New York, May 6. Photo: Annette Gaudino

Well before Bernie Sanders entered the presidential race, a nonpartisan group of 39 leading doctors set out to fix the glaring problems in the Affordable Care Act (ACA, or Obamacare). The single-payer plan they proposed, essentially Medicare-for-All, has since been endorsed by over 2,000 physician colleagues and published in the American Journal of Public Health, according to this article in Huffington Post.

The HuffPost article generated lots of reader comments, and I just had to respond because this is the sort of debate I love to jump into. It brings together many different perspectives, especially those of consumers who too often aren’t heard from by politicians. Here’s a summary of my responses and answer to the question, “Is Medicare-for-All enough?”

Medicare-for-All is Not Enough

As a consumer advocate and founder of Modern Health Talk, I whole-heartedly endorse the idea of a single-payer national health care system, as proposed by these doctors and by Bernie Sanders, but I think we need to go even further, but maybe not as fast.

Beyond just improving the efficiency of how healthcare is paid for and adopting the exceptionally efficient Medicare system for everyone, we need to address the NEED for medical care in the first place. To further reduce the costs of providing medical care, we need incentives that focus more attention on overall health and wellness.

Even Benjamin Franklin knew, “an ounce of prevention is worth a pound of cure,” but our medical schools primarily teach new doctors how to diagnose and treat illness. That further encourages today’s fee-for-service business model that pays doctors to do more, test more, prescribe more, and treat more symptoms to keep patients as paying customers. Wellness education and incentives, however, go against that perverse profit model, so they often aren’t part of the curriculum.

Medicare-for-All would be a good step in the right direction, and it would likely lead to other reforms that emphasize wellness, because doing that dramatically lowers costs, and because it removes the incentives to artificially pump up profits for shareholders of healthcare stocks.

Who Opposes EFFECTIVE Health Care Reform?

What’s at stake if we ARE able to actually cut health care costs to amounts paid by other advanced nations? Beyond the impact in lives and suffering, what might we do with the $1.5 Trillion/YEAR in savings? Would we lower taxes? Pay off the national debt? Help people out of poverty? Make strategic investments in education, research, and infrastructure? Who could be against that?

Steven Brill wrote a 32-page TIME Magazine special report in 2013 (http://www.mhealthtalk.com/why-high-medical-bills-are-killing-us/) where he described a medical industrial complex (hospitals, insurers, drug companies, testing companies, and equipment providers) that keeps its costs secret and spends twice as much on political lobbying as the military industrial complex — all to protect their perverse profits from illness and injury.

Any reforms that cut healthcare costs in half means they’d lose half of their revenue, impacting jobs and shareholders. So with Citizens United and the corrupting power of big money in politics, true health care reform seems futile without a major political takeover by concerned citizens, and that’s the sentiment that Bernie Sanders has tapped into.

Corporate Behavior and Rising Health Care Costs

The first duty for insurance companies, hospitals, and other corporations is to the shareholder, not the patients or doctors. To understand how corporations work and why they so often behave as sociopaths, watch The Corporation, a Canadian documentary at http://www.mhealthtalk.com/corporate-behavior-and-rising-health-care-costs/.

Protecting the Practitioners

Most doctors and nurses I know got into medicine to help people, not to become wealthy from their illness or injury. As we focus more on prevention, we need to help them develop new skills to fit that goal and their personal goals.

One of the comments on HuffPost article suggested subsidizing medical education. I can even endorse offering medical education for free to those who qualify and are willing to serve and public assistance in paying off (or forgiving) student debt for new docs. One of the many benefits of that would be to give us more influence over what is taught in medical school, including more emphasis on health and wellness and less on treating symptoms.

Practitioners may also need help in learning how to support the greater efficiencies of new technologies that are being applied to telehealth video calls, remote sensor monitoring, health data analytics, and medical tourism.

A government-provided, single-payer health care system should make it easier to promote these tech innovations and to encourage wider use of electronic medical records. That’s because the financial incentives today discourage Hospital-A from sharing records with Hospital-B, because they fear losing the patient/customer. Likewise, Hospital-B does not really want test results from Hospital-A, because without them they can charge for retesting. Single-payer makes so much sense to me as a long-term objective. And Medicare as a public option makes sense as a non-disruptive way to get there.

Long-term Objectives and Short-term Goals

We must apply measured reason to health reform and not rush into disruptive changes that may have unintended consequences, meaning don’t change too much at once.

Medicare-for-All is a good long-range objective, but Medicare as a public option seems more reasonable since it can ease us into that with less risk. It could also be made available wherever market forces aren’t working, such as in rural communities, states with just one insurer, and for people over age 50, thus leaving private insurers with younger and healthier customers. That should help drive down premiums for those still buying private insurance.

Developing a Healthy and Productive Population

The goal of lowering the administrative cost of delivering medical care is one thing, but shouldn’t the real objective be to develop a healthier and more productive population and workforce? Doing that would avoid much of the need for medical care in the first place, and a single-payer system can then lead to and facilitate this second objective.

Imagine the impact that a healthier and well-rested workforce would have on absenteeism and worker productivity, profits, wages, GDP, and global competitiveness. With that perspective, I can envision other public policy changes that improve health, including environmental pollution, the food supply, and addressing poverty. In my view, it’s all about getting the incentives right and making sure they match our goals.

By the way, what exactly ARE our goals as a nation? Think of that question as you cast your votes this November.

Efficiency Advantages of a Public, Non-Profit Health Insurance Plan

When just looking at the administrative efficiencies of public and private health insurance, the Institute for America in 2009 proposed A New Public Health Insurance Plan to reduce costs and improve quality. Here are some highlights:

  • Medicare has controlled costs much better than have private health insurers over the last 25 years.
  • The private health insurance market is highly consolidated and needs competition from a public insurance plan to lower skyrocketing premiums.
  • Administrative costs are dramatically lower under public health insurance plans, resulting in enormous savings to the system.
  • Bargaining power of public health insurance plans significantly reduces provider costs.
  • In a head-to-head competition, the public Medicare plan is much better at containing costs than private Medicare Advantage plans.
  • Independent analyses show substantial savings can be achieved from a public health insurance plan that competes with private insurance plans.
  • Quality and effectiveness innovations occurring under the public Medicare plan show that public health insurance plans have greater potential to drive the quality revolution than do private plans.
  • If Congress wants to drive value in the health care system, it can design a new public health insurance plan offered in an exchange that will be best positioned to lead these efforts because public health insurance plans [have no profit motive and] increase choice, competition and accountability.

Comments on “Why Medicare-for-All is Not Enough


    Medicare-for-All Isn’t the Solution for Universal Health Care (The Nation) — The health-care debate is moving to the left. But if progressives don’t start sweating the details, we’re going to fail yet again.

    A Single-Payer Healthcare System for All Americans — Isn’t single-payer just another way to pay for care, with nothing to improve care delivery or reduce the need? This question is why I say, Medicare-for-All is Not Enough, although it sets the stage for effective reform.

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