Every other wealthy country in the world has long since
figured out how to provide health coverage to its entire population. Every one.
And yet this is still controversial in the United States, as continues to be
illustrated by the recent Democratic debates.
Every one of those Organization for Economic Cooperation and
Development (OECD) countries has better health outcomes than the US as result
of covering everyone. The health outcomes are not always terrific, but better,
as a population, than ours. There are two components to how healthcare is
provided; one is how it is distributed (very inequitably in the US and much
more equitably in the other countries) and how well it is funded. The second
might depend upon a nation’s resources, the first upon its values. Some of
these other countries should, and could, increase their health funding (e.g.,
Canada) but the fact remains that they are doing better because they distribute
it better. And, even when well-funded, a national health plan costs less – far
less, in every other country – than we spend in the US.
So we have the money, and we are ostensibly spending it on
health care. Indeed, if we count not only the direct public expenditures by
governments (federal, state, local) for their employees and for Medicare and
Medicaid and S-CHIP and other programs, but also the income foregone by
government because the health insurance premiums paid by employers (although
not by employees) are tax-exempt, it is about 60% of our health expenditures. In
other words the US spends more PUBLIC money than other countries spend
altogether. Another way of thinking about it is that we are paying for a
national health program but not getting it.
So why does this continue to be controversial? Why do the
majority of Democratic presidential candidates not support it? Why do there
continue to be questions from moderators at the last debate asking Sen. Sanders
how much it would cost and how it would be paid for? One possible answer is
that these candidates and questioners are ignorant of the facts, and ignore those
repeated time and time again by both Sen. Sanders and Sen. Warren, explaining that
we are already spending more than it would cost for Medicare for All. The other
possibility is that it is part of a concerted campaign to obfuscate and lie
about the issue to protect wealthy and powerful interests.
Let us start with the first. Maybe they are just ignorant of
the facts, or maybe they are too stupid to understand them (I doubt that).
Sanders responded to a questioner that the cost of a national health insurance
system, Medicare for All, that covers everyone in the US for everything
(including things that we don’t get now with most health insurances, like
hearing aids and glasses ), with no out-of-pocket costs for co-pays or
deductibles, will cost less than we are currently spending. This is made
possible by re-directing those dollars currently being ostensibly spent on health care and actually spending them on health care, rather than on
administrative costs and profit for health insurance companies, pharmaceutical
companies, and some big health care providers. A new article in the Annals of Internal Medicine,
“Health Care Administrative Costs in the United
States and Canada,
2017”
by Himmelstein, Campbell, and Woolhandler (Ann Intern Med. doi:10.7326/M19-2818,
online publication January 7, 2020), shows that:
U.S.
insurers and providers spent $812 billion on administration, amounting to $2497
per capita (34.2% of national health expenditures) versus $551 per capita
(17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for
hospital administration; $255 versus $123 for nursing home, home care, and
hospice administration; and $465 versus $87 for physicians' insurance-related
costs.
This represents 31% of all US health care costs, twice the
rate of administrative costs in Canada. Since they excluded some areas that are
accounted for differently in Canada, it is likely an underestimate. They add
that “Of the 3.2-percentage point increase in administration's share of U.S.
health expenditures since 1999, 2.4 percentage points was due to growth in
private insurers' overhead, mostly because of high overhead in their Medicare
and Medicaid managed-care plans.” These are the Medicare (and Medicaid)
managed-care plans that the Trump administration lauds as the best part of
Medicare, as I noted in a quote from CMS administrator Seema Verma in “Scamming
Medicare: It's the providers and insurers, not the patients!”
on December 22, 2019. Another very recent piece, a systematic review of studies
on the cost and financing of single-payer health care in the US, “Projected
costs of single-payer healthcare financing in the United States: A systematic
review of economic analyses” published in PLOS One by Cai, et al. “found a high degree of analytic consensus
for the fiscal feasibility of a single-payer approach in the US.” (PLOS Medicine | https://doi.org/10.1371/journal.pmed.1003013
January 15, 2020).
So the other explanation, the more likely explanation since
these people are not, in fact, stupid and probably not at this point ignorant,
is willfully ignoring the facts because they threaten a status quo that is
extremely lucrative for a lot of big companies, insurance companies and
pharmaceutical companies especially, and a lot of big providers, hospitals and
health systems. (This includes those that are ostensibly “non-profit”, which
means that they don’t pay shareholders – and don’t pay taxes! – but doesn’t
keep them from making lots of money which they invest back into the services
that will make them more money – e.g., orthopedics, cardiology, cancer, ICUs --
rather than those the community as a whole really needs but are not money
makers – e.g., mental health, primary care, etc. -- and paying their C-suite
executives salaries in the millions!) These companies are absolutely not
interested in losing this money, and they are big contributors to politicians.
This is abetted, indeed stimulated, by a tremendous
disinformation campaign by insurance companies, following upon the model
developed by car companies and cigarette manufacturers. The most obvious is the
perversion
of the language of “choice”, exposed by former health insurance executive
Wendell Potter in the New York
Times on January 14, 2020. When they
say “choice” they mean choice of insurance plan. In addition to the fact that
most Americans are limited to a choice between one or two plans that their
employer offers, people don’t care about choosing their insurance company (“I’m
an Aetna guy!” “I love CIGNA!”); they care about choosing their doctors and other
providers and hospitals – the very things that the private health insurance
industry restricts!
But could we not, somehow, keep private insurance as an
option, as suggested by most of the Democratic candidates and pundits? A qualified yes. In countries that do this, say
Switzerland, there are private insurance companies but they are highly regulated.
ALL have to provide the SAME coverage and ALL have to charge the SAME price.
How do they compete? Wait for it -- on customer service!! Are US insurance
companies ready to do this?
To a disturbing degree, people are swayed by these lies.
Sometimes you hear the myth that goes something like “Americans don’t have a
sense of social responsibility like people in ‘X’ do”, but they do. As Cai
points out, “Public support for provision of universal health coverage through
a plan like Medicare for All is as high as 70%, but falls when costs are
emphasized,” even though almost all Americans would pay less for much more –
and critically, all Americans would
be covered. What is unacceptable is that the “responsible” media and
(hopefully, if we’re going to vote for them) “responsible” politicians, in the
debates and in their coverage, repeat these lies.
We also sometimes hear the question “what will all those
people who work for insurance companies do if they are closed down?” It is a
legitimate one, and one for which the Medicare for All bills prescribe
retraining, but the real issue is why is this asked only for this industry and
never about workers who lose their jobs because companies relocate their
manufacturing and services overseas? Why is the cost never an issue when we are
talking about military expenditures (not for pay for personnel, no, but for
incredibly expensive and profitable armaments), but only when we are talking
about people’s health?
Americans as a whole pay a huge amount for health care, in
premiums paid by individuals and their employers, in tax dollars for Medicare
and Medicaid, and in out-of-pocket co-pays, deductibles, and huge drug costs.
What we get are some people with good coverage, most people with mediocre coverage,
and a lot of people with poor or no coverage. Every
"scandal" about someone getting a $100,000 bill from an
out-of-network doctor at an in-network hospital, about a $30,000 / month
medication, about denial of necessary care, is not fluke but a built-in part of
our crazy non-system. Medicare for All, as in the
Sanders Senate
bill (S.1129) and the Jayapal House
bill (HR.1384) will cover EVERYONE for
EVERYTHING.
Let’s do it. Now. And let’s have
our media and politicians stop repeating the insurance-company funded lies
about it.