The call for a universal health care system in the US is
probably greater than it ever has been. While, of course, the Republicans,
whose only firm position is completely kowtowing to billionaires and major
corporations, are opposed to it, many Democrats have signed on to the “Improved
and Expanded Medicare for All” bill in Congress (120 at last count). Democrats
running across the country have been calling for “single payer” as well as “Medicare
for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in
NY (and of course Bernie Sanders) to moderate Democrats running in states and
districts that Trump won. They correctly see this as an issue that cuts across
traditional liberal-conservative lines, and even racial lines, and may be their
path to victory.
Many Republicans (although not the Republican congressional
leadership) are reading the same tea leaves, and are
hedging, trying to say that they favor the things that people like about the
ACA (most important, the protection against insurers denying coverage for
pre-existing conditions). Of course this often requires major dissembling for
those who, like our Arizona GOP candidate for Senate Martha McSally, voted to
gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz
Amendment” that would strip virtually all protections for people under ACA.
President Trump, never one for nuance, has no difficulty having it both ways:
he calls for the repeal of ACA while insisting that his health care plan will
protect people’s ability to have health insurance, pre-existing conditions or
not (it won’t).
It is in this context that the recent Sunday NY Times’
Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t
get too excited” about Medicare for All’ becomes important. For starters, “Don’t
get too excited” is not necessarily the opinion of the authors but a quotation
from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one
of his Nashville constituents, Dr. Carol Paris, President of the leading
physician advocacy group for single payer, Physicians
for a National Health Program (PNHP), that he had signed onto the Medicare
for All bill. Nonetheless, the article does raise many cautions about the
movement to single payer or Medicare for All, mainly about different
interpretations of the meanings of this by different advocates, and incomplete
and sometimes inaccurate understanding of them by regular people. The most
important thing about it, however, is that it had to be written at all because
there is such a movement; long-time activists, including PNHP physicians,
remember that it was not too long ago that such an idea was poo-pooed,
dismissed. Not now.
Clearly, the quantum step forward was the 2016 presidential
campaign of Bernie Sanders. The establishment pundits of both parties were
shocked at how popular and successful this old Jewish socialist from Vermont
(ok, originally Brooklyn) was across the country. He didn’t win the Democratic
nomination, true, but he might have won the general election against Trump.
Certainly, his straight talk and the fact that he directly addressed the felt
needs of regular people was the main reason for his popularity, and people’s
fears about their health risks and costs were central to this (see A
majority of Americans are worried about health care costs -- and a majority of
Congress doesn't care, October 16, 2018). Bernie had advocated for
single payer for decades, as had great leaders before him including the late Representative
Ron Dellums of California (see Ron
Dellums: Loss of a great leader and a job for the rest of us, July
31, 2018), but the visibility of his presidential campaign skyrocketed the
visibility of single payer.
Rosenthal and Luthra utilize a good bit of ink describing
what single payer is --the government is the only payer for health care, rather
than multiple private insurers; Canada is the best example of this, and Britain
has a government-owned national health service. They also note that Medicare
for All means exactly that, that everyone, not just those over 65 and the blind
and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be
single payer. They describe the misconceptions people have (“would I be able to
keep my present plan?”), and also talk about other countries, such as France
and Germany, that have universal health care without a single payer but with a
heavily-regulated marketplace. They observe that partialist solutions do not
generate the enthusiasm of single payer, but that the latter would be the
hardest and thus (perhaps) most difficult to institute. Among the concerns they
note are the displacement of insurance company employees and the decrease in
doctors’ income.
But these are the most important points.
But these are the most important points.
- Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
- Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
- Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.
These are the core issues that need to be addressed, and
what sets the US apart from all other developed countries. Yes, Canada has a
single payer system such as we might have with Medicare for All (and they even
call it Medicare). Britain has a National Health Service, with most hospital
and health care facilities owned by, and some doctors employed by, the
government. Britain, however, allows private insurance for those who can afford
it, Canada does not. France and Germany and Switzerland have multiple insurers,
but they are not unfettered to maximize profit by denying care. In Switzerland,
for example, insurers have to be non-profit, have to offer the same benefits,
and have to charge the same amount. They compete on quality of service! Can you
imagine that here?
So, while Rosenthal and Luthra repeat the idea that single
payer, although the most enthusiasm-generating, would involve the biggest
change, it is also, in another sense, the least complicated. Trying to get to a
system like that that evolved in these other countries over decades will be
more complicated to understand and to implement. Many of the suggestions for
incrementalism (“Medicare for More”, “public option”) will not solve the
problems we have because they do not include everybody, and because they do not
eliminate the incentive for making money on the back of denying care that is
the core flaw in our current situation.
“Medicare for All” and “single payer” are popular among people
because their core meaning is understandable, and they would address the needs
that they have.
- · Everybody in, nobody out!
- · No profiteering!
Simple message. Needed solution.
