IMPROVED and Expanded Medicare for ALL. Now. The people want it!

I am in favor of the US having Medicare for All, specifically Improved Medicare for All, as defined in the two bills currently before the Congress: S 1506, sponsored by Sen. Sanders and 18 cosponsors, and HR 3069, sponsored by Rep. Jayapal with 117 co-sponsors. It is important to emphasize the “improved” part, because the deficiencies of current Traditional Medicare (TM), of which there are many, have been used by opponents of Medicare for All, to argue against it and to push various methods of privatizing Medicare, particularly Medicare Advantage and the WiSER program.

The deficiencies in the current TM program involve what is covered and cost. Some things are not covered by TM, including glasses, hearing aids, and nursing homes. This is ridiculous and is due to lobbying pressure by those industries, which want to ensure their profitability. Cost issues include, prominently, 3 things: Part B premiums (which are scaled to income, but start at $203 a month), Part D premiums (thanks to the GW Bush administration, Medicare now requires beneficiaries to have drug coverage, but also requires that it be purchased from a private insurer, and is not available from the federal government), and Medicare Supplement plans, which pay for the portion of covered services that Medicare does not. This is different from the services Medicare does not cover, like hearing aids or glasses, which the Supplement plans also do not. It is, most significantly, the 20% of a hospital’s Medicare-approved charge that Medicare doesn’t pay for. A hospital may normally charge, say, $40,000 for a stay including surgery and post-op care, but Medicare has an approved charge, say $10,000, and that’s all the hospital can bill the Medicare beneficiary. But then Medicare pays only 80%, so the patient is on the hook for $2,000. That’s largely what Medicare supplement plans cover.

So, the Part B and Part D premiums, and the need to buy a Medicare Supplement from an insurance company, can cost a good deal. This can make Medicare Advantage plans, which are basically HMO or PPO insurance products sold by the same companies that issue commercial insurance, and cover drugs as well as 100% of hospitalizations, look financially attractive. Plus, they also cover hearing aids, glasses, and sometimes dental. And even gym memberships! The potential disadvantage is that they are insurance company products and subject to the same limitations as most commercial HMO/PPO products. The most important are:

•          Limited networks. Only some doctors and hospitals are in the network they pay for. Yours may not be. Or your hospital may be, and your doctor may be, but the ER doctors who care for you in the hospital are not. Or the anesthesiology group. Surprise charges! And most are geographically based, like most HMOs and PPOs, so it may be hard to get non-emergency care away from your home area. And some “destination” hospitals, such as Mayo and MD Anderson, do not accept MA. Virtually all doctors and hospitals accept TM.
•  Denials. Most people who have commercial insurance have experienced denials of claims. Often it seems as if denial is the default (perhaps AI generated). These decisions can be appealed, but most people don’t appeal. And then it can be denied again, multiple times, for little or no reason. It is part of the business model of health insurance companies. For TM, a covered service is a covered service. It cannot be denied.

It’s not as if this will always happen with MA; as with other insurance products, the coverage varies. But it happens a lot, and unsurprisingly, happens most often to those with the lowest-cost products as it does with non-Medicare commercial insurance.

So, the Improved part of Medicare for All is crucial. It needs to cover all necessary health services, not just hearing aids and glasses, but nursing homes and rehabilitation and comprehensive mental health and dental health. All the things that have been cut out as sops to powerful lobbies. And it needs to cover 100%, not 80%, of approved charges. And let me not leave out the All part. That means everyone, birth to death, no exceptions, no carve-outs, no people or groups of people who are in a different plan, no Medicaid, no ACA. Just one program that covers all of us for everything. A single-payer, universal health insurance plan. Like every other wealthy, and most middle-income countries, have.

But Americans don’t support this, right? Well, actually, they do. Recent polling from GQR reveals 94% of Democrats support M4All! And yet Rep. Hakeem Jeffries, the House Democratic leader has recently joined other prominent “mainstream” “centrist” Democrats in announcing his opposition to it, instead favoring yet more inadequate piecemeal “reforms”. Rep. Jeffries: Get with the program! 94% is more than a lot. It is almost all! And it is not just Democrats: GQR also reports

 Massive support among base voters:

● 94 percent among Democrats;

● 94 percent among self-ascribed somewhat liberals;

● 73 percent support among Black voters;

● 76 percent support among women under age 50; and,

● 75 percent support among voters under age 30.

 

Impressive support among swing voters and notable support among Republicans:

● 60 percent among Independents;

● 67 percent among moderates;

● 60 percent among non-college women;

● 66 percent among college educated men; and,

● One in five (19 percent) Republicans and Trump voters support MFA.

Hmm. It is almost as if the Democratic leadership is not interested in welfare of the American people. It almost seems as if, rather, they are interested in appeasing their big donors.

Think about it. When you look at your own experiences with the healthcare system and health insurance companies, and those of your friends and family, it is scarcely a surprise that Americans hate the current system and are not particularly interested in partial solutions which cover some people for some things by method A, and others by method B, and still others by insurance so poor it covers little (method C), or others not at all (method D). The Commonwealth Fund reports that one-third of Americans 19-64 (pre-Medicare) are paying off medical debt, 46% of whom owe at least $2,000, and more than 1/3 used part or all of their savings to try to pay it off.

In addition, millions of Americans are experiencing “job lock”, a situation in which people feel that they have to stay in their current job to maintain their health insurance, rather than being able to find a better job or start a business. ValuePenguin reports that this amounts to 40% of US adults! Wendell Potter, in his “Health Care Un-Covered” correctly notes that the ACA does not solve this problem, nor does any hodgepodge approach. This concept is something that is completely absent from people in other countries -- because they have universal health insurance.

The American people are not interested in partial fixes anymore. They want to have freedom to work where they want and not have their lives ruined by medical debt so that health insurance companies can rack up even more profit (why would they?). They want the comprehensive, easy to understand, effective type of universal health insurance that has been proven to work, in many forms, in most other countries.

It is past time for Improved Medicare for All!

We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.