‘Medicare for all’ is the wrong goal and we need a new system
The Sanders description of “Medicare for all” is a utopia: everyone has access to their doctor of choice when they want, all services are paid for without deductible and copay and what people pay for health care in taxes is less than what they are paying now.
In that utopia, why would anyone need private insurance? There is no private insurance plan that any union could negotiate that could be better than that utopia.
This very utopia is proposed by a number of presidential candidates, with or without private insurance. The confusion after two debates is deafening.
As Bob Bryan once coined the phrase, “You just can’t get there from here.”
Here are a few reasons why:
1. Medicare for all will be wildly more expensive than even current estimates. It covers everything: expensive cancer drugs, transplants and as medical progress moves forward, more people will live longer with chronic disease. To say that everyone will ultimately pay less comparing their current health-care expense to their future taxes is just not so. How about the 30 million uninsured paying nothing right now.
2. The money can’t come from making people healthier. Don’t for one minute think they are cheaper if they have health insurance. Preventing disease is the right thing to do, but most often it does not save money.
3. So you remember the problems Medicare had with information technology signing up a few million people at the beginning of the Affordable Care Act? Imagine adding 300 million to a current system. Better to start over. The CMS administrator in a recent op-ed thinks this, and the public option, are just not practical.
But here’s a new thought: Medicare for all is not even the right end-game. No other country has a purely public “single payer” system. In Canada, the public system does not cover prescription drugs, home care or long-term nursing home care (paid in the U.S. largely by Medicaid). In fact, a full 30 percent of costs are covered by their private system.
In the UK, “everything” is covered by the National Health Service. No it isn’t. And the UK points out the tragic flaw of the Medicare for all utopia in the U.S. The UK rations. It does not permit the use of many expensive drugs and tests. And given the limited budget of the public system, certain procedures have to be “put off until next year” as they have spent the allotted amount – leading to waiting lists. Private insurance in the UK (21 percent of UK health spending) buys access to expensive drugs and permits rapid access.
So, what’s the point? Stop calling this “Medicare for all.” There is no country in the world that has a system remotely like Medicare for everyone. It’s the wrong goal. Call it “health care coverage for all” or “universal coverage.” This is not just semantics.
But the eventual system that supports that goal will need to be carefully constructed and not look a bit like Medicare. The elements are the same as all other countries, the foundation of a “single safety net.” This is like public school where everyone pays their taxes and everyone is covered. But there is also private insurance that individuals and companies can buy – like private school. Why do we need insurance? Because, as the rest of the world has learned, a private system can provide basic care but it surely cant meet the desires of everyone. And, in practicality, good luck closing down private insurance in the U.S. How to pay for it?
We should give smart people the duration of the next president’s first term to develop that system. Then take the next four years to phase it in.
But while the smart people are thinking about it, we should deliberately figure ways to cover all the uninsured right now. The simplest way to do that is to have the federal government to cover newly-added Medicaid members in all states covered at 100 percent – no state in their right mind would turn that down.
Then subsidize the purchase of private insurance for those who can’t afford it. But really subsidize — so that all out of pocket is less than 6 percent of household income for anyone not on Medicaid. How do we pay for it? If we bring in less than half of the $1 trillion out of the system that we currently waste, we can have money left over. There are all these calls for reducing the cost of health care. We can get after it today.
Is this expansion of the Affordable Care Act? Yes, but this would be a transition over eight years to the best health care system in the world. The end-game is not Medicare for all.
Dr. Arthur Garson, Jr., M.D., MPH is the director, Health Policy Institute at the Texas Medical Center. He is also a member of the National Academy of Medicine and a former president of the American College of Cardiology.
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