Health Insurance is not Healthcare: Everybody in, nobody out!

 I have long advocated universal health insurance, recently in the form of Improved and Expanded Medicare for All. What “Expanded” means is obvious – EVERYONE would be in it. As the late Quentin Young, MD, was famous for saying “Everybody In, Nobody Out!”. That should be simple to understand. The “Improved” part means “not having the limitations of current traditional Medicare”. This means also covering dental, vision, hearing, and long-term care. And, most important, to eliminate the 20% of the amount that Medicare approves that patients are responsible for paying for hospitalization (Medicare pays 80% of approved hospital charges), or at least capping the dollar amount (not %) that people have to pay out of pocket. More detail is presented in the Physicians’ Proposal by Physicians for a National Health Program (PNHP), and is essentially what is proposed in the Medicare for All act, HR 3421, sponsored by Rep. Pramila Jayapal (D-WA) in the House, and the companion Senate Bill, S. 1655, sponsored by Sen. Bernard Sanders (I-VT).

I would like to address several important issues about why EVERYBODY IN, NOBODY OUT, expanded coverage for essentially all medical care, and the different between having health insurance and having health care. First a quick review of some of the important places where health coverage was expanded, just for background.

When there was a limited amount that doctors could do for people, folks accessed medical care with cash (or chickens). When hospitalization and surgery became effective for many conditions, insurance like Blue Cross/Blue Shield were established, mainly by surgeons. These were for a long time non-profit. After WW2, because the federal government implemented wage and price controls, even though there was a labor shortage companies could not compete by paying higher wages so benefits, like health insurance, became attractive. This was embraced by organized labor, which could exhibit such insurance as a member benefit. In 1965, Medicare was implemented to cover aged and disabled people, a huge advance. Medicaid, a program for low-income people who could not afford health insurance, was also a huge advance, but as a federal/state partnership, who and what it covers varies a lot from state to state. The ACA passed in 2010 (Obamacare) further expanded coverage by making health insurance affordable for many more Americans. This is the really short course.

 

As can be seen in the graphic (from Statista®) the number of uninsured people in the US has, as a result of the programs above, dropped dramatically. There are, however, 3 big problems that continue to exist. First, 25 million is a lot of people without insurance. Second, having health insurance, in the current chaotic system, is not an all-or-nothing thing. Many “insured” people have poor quality insurance, with high deductibles, high copays, caps on coverage, and high rates of denials by their insurance for treatments recommended by their physicians. Even people with “better” (and often more expensive, and likely paid in part by their employers) health insurance find themselves confronting these same trends with costs often making getting care unaffordable. The key lesson here is “health insurance is not healthcare”; if the care you need is unavailable to you because it is unaffordable despite having some form of insurance your health is not improved. This is what I will mostly talk about below.

Third is what changes will happen with the new Trump administration. We cannot know for sure what it will succeed in doing or even try to do, but it won’t be good. He and his advisors want to get rid of the ACA. They want to further privatize Medicare by moving more people into Medicare Advantage plans, which are private insurance plans paid for with public money that can and do often deny you care. (see Such a deal! Insurance companies keep your money and deny you care! How can I get in on that?, Oct 28, 2024.) If you want to get more information, check out the Project 2025 proposals for health care and health insurance.

So, let’s get back to the second, that having health insurance is not the same as having health care. This should also be obvious, but apparently it is not to a lot of people, including politicians, pundits, and health economists. For most things we buy, we trade off quality and price, usually assuming that higher price will lead to higher quality. With health insurance, it is sort of that way, but unfortunately the price is so high that many people buy the lowest cost (and lowest quality) because that is all that they can afford. It is why so many people have high-deductible plans that, when they need to use them, are not actually useful for obtaining health care because the deductibles and co-pays are so high. It is why the lowest cost ACA plans are the most popular and deliver the least. And it is one of the main reasons why so many seniors have opted for Medicare Advantage (MA) plans rather than traditional Medicare (TM). The entry cost is lower, they cover some things TM does not (like glasses and hearing aids and dental) and it does not require purchase of a Medicare Supplement (Medigap) plan to cover the 20% of approved hospital charges that TM doesn’t pay. But when folks get sick, they may discover that the MA plan does not cover the hospitals or doctors they want and that, because they are private insurance plans and not, in fact, Medicare, they can and do deny coverage for lots of things. Oh, well. You want a lot of detail on how bad it is? Look at the Commonwealth Fund’s Biennial Survey, “The State of Health Insurance Coverage in the US”.

Why do we demand such premiums, deductibles, and co-pays? A lot of health economists have used the term “skin in the game”, implying that if people have to pay some of their own money they won’t “over-use” health care, which drives up the cost. This analogy to gambling is flawed, and wrong. There is no evidence that “over-use” is a major driver of health care costs, either in the US or, more importantly, in other countries where the direct costs to patients are non-existent or very limited with low caps on the maximum that people can spend out of pocket. It is a theoretical belief not supported by the data. And politicians, pundits, health economists, and newspeople are employed, usually with relatively high incomes, and what seems to them anecdotally to be “not so much” (a few thousand dollars?) is so high for many Americans that they forgo health care altogether.

The cost of US health care is indeed extremely high, but it is not because people over-use services. Physicians often over-use (over-order) services because they can see the benefit but not the cost, because they may make money from procedures and even more from their use if they also own, say, the imaging center, and because they fear lawsuits if they do not. But most of the excess cost of US health care compared to other countries (many of which actually use more health care per person than we do, in terms of things like hospital beds per population) is the excessive administrative cost and profit on the part of health insurers and large care providers like hospital systems.

What can we do? Well, we can eliminate for-profit insurance companies, or regulate the heck out of them so that, as in countries like Switzerland, they have to provide the same set of benefits at the same price, cannot make a profit, and have to compete on – get this – customer service! We can have one single-payer plan, Medicare for All, improved to cover everything and expanded to cover everyone. In the meantime, we can at least cap the out of pocket maximum people have to pay to, say $1000. How could we fund it? Let’s start with the $590B in overpayments to Medicare Advantage plans!

A year ago, Levitt and Altman wrote about the complexity of the US healthcare system (Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Health Forum), and included this:

 “Yet, any push for health care simplification inevitably clashes with commercial interests. The health insurance system is structured to simultaneously maximize profits, control costs, and serve consumers, which are competing goals that add to the challenge of simplifying it.” 

OK. Can any decent person even consider that the value of “maximizing profits” should have any weight compared to “serve consumers”? It might be the defining question as to whether one is a decent person!

Finally, though, we need a system to cover everyone, well, so that they can really get healthcare.

EVERYBODY IN, NOBODY OUT!

 

Being blown off by health care can cost you your life...

Dealing with corporations is hard. Robots answer your calls, but not your questions. They are programmed to give you the information the company wants you to have, not the answers you need. It is very difficult to ever find a “monitored” email address to write to. It is like they don’t want to hear from you (except in the ubiquitous and totally structured “tell us how we’re doing” requests). Charges (as I experienced recently) are posted to your credit card immediately. Refunds, even when they agree to one, can take 45 days (by policy).

People, on the other hand, are almost always good and helpful. If you have the time and patience and willingness to scream “representative” at the phone often enough to actually get one, they mostly are polite, empathic, and usually resolve your problem (unless such resolution is prohibited by company policy). At least they answer your questions. It is amazing but not surprising that companies make it so hard to get to them. After all, they may help you out. Which is not what the company wants; they want your money and you be gone! Robots are also cheaper, thus increasing profit (and unemployment).

And so it is with healthcare. In which case it can be a disaster. I don’t mean that the waste of your time and money with other corporations is ok, or even just bad, or that it cannot financially be a disaster. But in health care we are talking about the health and even lives of you and your family. If you can’t get hold of your health care providers, you can’t get seen and cared for, or get the information that you need to do what you need to do, or to be seen elsewhere. This is, again, not the fault of or the result of the actions of the actual people who care for you, who if you can get in to see them or speak to them on the phone are usually very helpful. It is the fault of the system that is structured to prevent you from getting to them, because less use by you results in more profit for them.

That, of course, is at the provider level. At the insurer level, we enter a whole new region of Bizarro World. You get insurance. You find a provider. You see your provider. They recommend a treatment plan. You agree. Now the insurance company, which has a policy requiring “prior authorization” for virtually everything, denies payment. There may not be a good, or even any, medical reason for denying payment, and, if you appeal, they may pay because, after all, there is good medical reason. But denial as a first line response is great -- for them. Most people don’t appeal. They often don’t know that they can, or how to. So, for the insurer, problem solved. Of course, their problem was that they were going to have to pay money, and now they don’t. Your problem? Not solved. And your problem was your health, treatment for your disease. Whoops.

Prior authorization is an effective tool used by insurers to not pay for your care. It is more ubiquitous in “managed care” plans (HMOs, PPOs) than in open insurance plans. Of course, the latter are getting much rarer. It is cheaper for your employer to enroll you in a managed care plan. (Noticing a theme here?) Medicaid the (almost always dreadfully inadequate) public state/federal partnership for covering the poor is mostly (41 states including DC) turned over to managed care. One of the last bastions for fee-for-service, Medicare (the federal insurance plan for the aged, blind, and disabled) is quickly moving in that direction, with over 50% of Medicare patients not enrolled in actual Medicare but rather in “Medicare Advantage” (sic) programs, essentially private HMO-type plans paid for with Medicare funds. Now Medicare patients too can experience the advantages of managed care (like eyeglasses and gym memberships) as well as the disadvantages (like limited provider networks and denials of payment when you actually get sick).

A lot of the burden on privately-insured patients is demonstrated in research by Sukreth A. Shashikumer et al. in Financial Burden of Health Care in the Privately Insured US Population,
JAMA Internal Medicine, May 28, 2024, and summarized in the Health Justice Monitor.  

Among low-income families, mean total health care spending was $3163 in 2007 and $3247 in 2019. Low-income families’ medical burden was 23.5% in 2007 and 26.4% in 2019.  Among higher-income families, mean total health care spending increased from $4071 in 2007 to $5239 in 2019. Higher-income families’ medical burden was 5.4% in 2007 and 6.5% in 2019.

It’s bad for everyone but is, as always, worse for lower income people. This is also described in detail in a recent article by the Associated Press’ Tom Murphy, “Being a patient is getting harder in a strained and complex US health care system” (June 2, 2024), which describes the direct negative impact of insurance company denials on people’s health. The article discusses how some coverage for patient navigators helps, but the core problem is that is in the interest of the insurer to not spend money. Some MA plans like to say that they are enhancing health equity by covering a lot of low-income and minority people. Of course, this is only because the up-front costs are less. Those people pay when they get sick not only with dollars (co-pays, deductibles) but with their health (limited networks, denial of care).

And the majority of Medicaid recipients are children, and they are not immune from being denied care by their insurance companies, as revealed in a report from the General Accounting Office (GAO) and described by Wendell Potter in his “Health Care Un-covered” substack. It reports that insurers use both prior authorization and denial of payment for services, called EPSDT (Early Prevention, Screening, Diagnosis and Treatment) that the law REQUIRES be provided!

Contrasting traditional (real) Medicare with Medicare Advantage is useful here. You pay into Medicare your whole working life. When you are old enough and receive it, traditional Medicare pays for the services you receive (with some important limits, mainly only 80% of hospitalizations, requiring a Medigap plan). Medicare Advantage however, receives the money for your care from Medicare up front. Their incentive, then, is to keep it, by spending as little as possible on your care. That’s it in a nutshell. It is described in more depth in the report from Physicians for a National Health Program (PNHP), “Taking Advantage: How corporate health insurers harm America’s seniors.”

It is awful how badly corporations treat people. The laws and regulations need to be changed, to require them to provide the goods and services they have been paid for, and to make access for concerns or complaints, including access to actual people, easy. But completely different rules need to be in place for healthcare. If I can’t get through to most companies until Monday, I can live with that. If my credit card company keeps me going through the hoops on the phone for a half hour or more before I can talk to a person, I am only wasting time. But if this happens when I am trying to access health care, I can get very sick or die! Waiting 6 hours to be seen in the ER is not the answer. Neither are prior authorization, denials, and delays, for sick children, vulnerable seniors, poor people, or any of us.

What can we do? Write and call our congresspeople and demand that they eliminate profit-making insurers from healthcare. Perhaps some are not stupid (believing what lobbyists tell them, such as that Medicare Advantage increases equity) or corrupt (gleefully accepting those lobbyists contributions) and actually care about the health of their constituents.

Tell them to sign on to the Improved and Expanded Medicare for All bills in the House (Pramila Jayapal and Debbie Dingell, primary sponsors) and Senate (Bernie Sanders), and to sign the Patients Over Profits pledge being promoted by National Nurses United and other organizations.

Or you won’t vote for them.

Why do we have to wait so long to see the doctor? It's all about the money...

I have seen a number of articles describing the difficulty of getting doctor’s appointments in the era of COVID-19. In many parts of the country it was difficult to get a quick appointment even before the pandemic, but it has become much worse. I hear from friends in a several different cities that they cannot get into their doctors offices for weeks or, commonly, months. This is not OK for routine care; it is certainly not ok when something urgent, or relatively urgent, or even a little bit “needs to happen before I get really sick” is going on. A recent article in the Wall Street Journal by Devorah Goldman (‘The doctor’s office becomes an assembly line’, December 30, 2021) describes a woman who came to her father’s Brooklyn office from New Jersey because she couldn’t get an appointment for 8 months!

There are Emergency Rooms, of course, but waiting (frequently for hours!) in them increases your risk of acquiring COVID infection. And, as in “regular” times, they should be for emergencies, not for care for chronic diseases or minor acute disease. Of course, if you cannot get regular care for your chronic disease, it can become an emergency. And, as I have written before (Emergency services, COVID, and the health system: Your life could well be at risk, Jan 19, 2021), when you have an emergency, like a ruptured appendix, waiting in an ER for hours is also very dangerous, and the more “non-emergent” people waiting the more likely this is to happen. There are Urgent Care Clinics, but these have their own issues: they can only take care of a limited (and variable by location) menu of problems, most of which are those your mother used to take care of, and they may not take your insurance (if you have it). Also the prices and profit margins are very high.

So why are the waits so long, and what can be done about it? Goldman’s emphasis is the takeover of physician private practices by hospital systems and large groups; she notes that, according to the AMA, 75% of physicians owned their own practices in 1983, but by 2018 it was 46%. This is part of the problem; even if an individual physician is compassionate and caring, the big corporation they work for probably is not. Another part is the maldistribution of physician specialists. Studies of efficient and effective health care systems indicate that 40-50%+ of physicians should be in primary care, seeing people for most problems, providing continuity of care for a patient panel, and diagnosing “undifferentiated patients” (those who do not have a specific diagnosis) and caring for them or appropriately referring them. In the US, however, it is less than 30% and dropping. Quite reasonably, subspecialists want to see people with the problems that they know how to take care of; this works well when they are referred by family physicians and other primary care clinicians, and much less well when people have to self-refer, essentially having to diagnose themselves. Such direct self-referral also backs up the subspecialist practices with patients whose problems could have been well taken care of by a primary care clinician (not everyone with a heart needs a cardiologist!) making it more difficult for those with complicated or rarer conditions that need the subspecialist’s care to get in. Medicare’s reimbursement method figures prominently in Goldman’s article; she identifies ways that it tends to give preference (i.e., pays more) to large, and especially hospital-owned, medical groups. And, of course, since COVID the demand for care has gone up, and the number of clinicians available (because of sickness and overwork) has gone down.

Many other articles claim to provide the reasons for this problem, and some even have proposed solutions, but most of them examine only one aspect of it. I am reminded of the old Indian story about the blind men and the elephant, each touching a different part of the beast and thus presuming, based on contact with the trunk, the tail, or a leg, that they knew what the whole elephant looked like. Often this is influenced by the agenda of the writer and whether (like, e.g., Goldman) they get their information mainly from groups like the AMA (“oh, for the days of physician-owned private practice!”), hospital associations (“consolidation is good!”), government agencies (“reimbursement policy is governed by competing needs”), or academics, think tanks, or nonprofits like the Commonwealth Fund, Kaiser Family Foundation, and Pew Trusts, often with their own biases. To me, it is clear what the whole elephant looks like, what is the common factor in this equation, what can be seen behind all of the decisions that have led us to where we are (and continue to make it worse) and, by implication, could show us the way out: Money. Corporate profit.

We live in a profit-driven capitalist society. More than that, we have moved well beyond simple “Adam Smithian” capitalism to what Noam Chomsky identifies as “gangster capitalism”. In this stage, merely making money is not sufficient – the only goal becomes to make ever more money, by any and every means possible, no matter who, or what is destroyed. This includes people, animals, plants and the earth itself -- it hurts, screws, destroys, even though neither those who control it nor their descendants could ever spend it all. Fewer and fewer people control more and more and it would be naïvete to assume this is not the case in health care.

Virtually all the systemic bad things (as opposed to the much less common individual error) in healthcare derive from corporate owners’ efforts to make more money, and to game the system to maximize profit. While huge practice groups owned by hospitals or investors could operate more efficiently to improve both the quality of and access to care for patients, they don’t since they are interested in squeezing every dollar of profit. Conversely, small physician-owned practices couid do better than they do, but often, in pursuit of income, do not care for significant portions (poor, uninsured, badly insured) of the population. Explicitly for-profit (as opposed to ostensibly non-profit, but still fixated on making as much as possible) healthcare entities, whether large hospitals and hospital systems or more ‘niche’ services like dialysis, physical therapy, and long-term care, are the worst. There is certainly plenty of blame to go around – healthcare systems blame insurance companies for not paying them enough and insurance companies blame healthcare systems for demanding too much, but both are seeking to earn money for themselves, not to ensure all people get the highest quality health care.

Pharmaceutical companies are notoriously rapacious. For example, see Aduhelm® (FDA approves Alzheimer's drug against the recommendation of its scientific panel. Be very concerned, June 21, 2021); every (60 million!) Medicare recipient’s Part B payments will now rise $11/month so some Alzheimer’s patients can receive this drug that, though probably ineffective, costs a huge amount (now, graciously, reduced to only $28,200/year!). It was approved by the FDA over the recommendation of its scientific advisory panel in a move completely reminiscent of the fraudulent labeling of Oxy-Contin® described in the film “Dopesick”, which I recently discussed ("Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!, Dec 7, 2021).

I have often advocated for a single-payer health insurance system, such as Medicare for All. The advantage of this would be that 1) everyone in the US is covered, and 2) everyone in the US has the SAME coverage, The second is not a minor point, as it means that the educated and powerful will make sure it works, also helping the disenfranchised and disempowered. A universal health insurance system (or something comparably effective) is necessary, but not sufficient. Medicate for All needs to be an improved and expanded Medicare, as described in the bills introduced by Sen. Bernie Sanders, Rep. Pramila Jayapal and others.(See this good analysis by Sen. Sanders on the “Vulgarity” of the US health system.) It must be expanded to cover not only everyone but everything (mental health, dental, vision, hearing, long-term care) and improved to cover them completely without co-pays, co-insurance, deductibles. This will eliminate the flaws Goldman describes in Medicare payments.

Since we already spend 2-3x as much per capita on health care as any other wealthy country, including premiums, deductibles, co-pays, government benefits, and the profits and administrative costs sucked out of the “healthcare” pool by insurers and providers, we don’t even need to tax the richest a lot more to pay for it. We just need to spend it on actually providing healthcare! Not that we shouldn’t make the billionaires and corporations pay at least their fair share of taxes; we can use that money to providea adequate housing, food and education to all our people – really, the biggest factors in health.

Don’t get distracted by the circuses and diversions created by those with a profit-motivated dog in the fight. Profit has little place in healthcare. Obscene profit has none.

"Values" based care: Public Health, Primary Care, and Medicare for All

Recently, a class of undergraduate freshmen I teach debated the issue “Health Care is a Human Right”. Although we later determined that most of them personally supported that statement, the “no” team did a good job marshalling the arguments of opponents, often citing those of libertarian think tanks such as the CATO Institute (originally founded as the Charles Koch Institute, in case that helps), which identifies itself as promoting "free markets and individual liberty”. This includes identifying health care as a “commodity” and opposition to health care as a right (and thus to universal health coverage) as an infringement upon individual liberty. Essentially these two concepts boil down to the idea that the individual is free to decide what kind of health care they want, or don’t want, and what kind of insurance coverage they want, or don’t want, and can use their money (or not) to purchase this commodity (health care) as opposed to another (I don’t know, say a bass boat).

The hole in this argument is wide enough, though, to drive a bass boat through. It is that not everyone has such a large amount of disposable income that they have the financial options to make such decisions. An old point about commodities having to do with cars, when most Americans bought American brand cars, is that some folks can buy Cadillacs and others Chevrolets. But of course, even if we update this to Beemers and Kias, there are a huge number of people who are buying used cars – often old “junkers” – to try to get to work and shopping. And there are those who can’t afford to buy, insure, and run any car at all and are reliant on public transportation. If there is any public transportation where they live. People without a lot of money (often despite working multiple jobs, even those making quite a bit more than the federal minimum wage of $7.25/hour -- last raised in 2009 when $7.25 was equivalent to about $9 today) make regular trade-offs on what they will spend their money on. Rent? Food? Clothes for the kids? Heat? Electric bill? Gas for the car to get to work, if they have a car? Health and medical care are rarely right up there at the top unless they are actively ill. Indeed, often even chronic diseases don’t get adequately managed, with medications for common conditions such as diabetes and hypertension stretched out. This family – and to a greater or lesser extent, this is probably true of the majority of families – is trying to figure out how to juggle absolute necessities, not luxury goods. The students arguing the “anti” position gamely tried to respond to such concerns, but learned that, outside the walls of conservative think tanks, Congress, state legislatures, and country clubs, there is a limit to the effectiveness of continually repeating “individual liberty” and “commodities”.

Paying for the cost of health care is a real juggling act for the government, although for a different reason from the one the families above are doing. It is balance between wanting to spend less money and continuing to support the profits of health care corporations such as insurance companies, hospital systems, and drug makers. The rational solution to this problem is to decide that it is not the government’s business to guarantee the often obscene profits of such private corporations, but rather to spend the money on whatever maximally increases the level of health of the American people.

This should include at least two major changes: first, a national health insurance plan (such as “Medicare for All”, recently reintroduced with major improvements by Reps. Pramila Jayapal and Debbie DIngell) that ensures that everyone is covered – everyone, all in one plan, no exceptions by age, disease, etc.), and second, a massive and continuing re-investment in public health, the need for which should have been made clear by the COVID pandemic. Historically in the US, in Democratic and Republican administrations, funding for public health is about 1% of the health budget, with the rest going to individual medical care. When we have a crisis, we bemoan the lack of public health infrastructure for a while, but then it recedes. Yet this is the most important component of keeping us healthy. Fighting an active enemy (like COVID) can garner support, while maintaining programs of prevention absent an obvious crisis gets less. How often do we wake up and say “I’m glad I don’t have cholera today because we have clean water and sewage”? And, yet, recently folks in Mississippi and Texas can count themselves lucky that their lack of water did not come with cholera or another infectious disease.

Instead of such wholesale reimagining we have had programs like “value-based care” for Medicare, adopted with the ACA (“Obamacare) in 2010. When this was first rolled out, I was enthusiastic because I misunderstood it – I thought it was about providing care based upon values, presumably decent human values. Sadly, I was wrong. It was about spending less money. Did it work? To do what? If the goal was spend less, yes, to some degree (see Austin Frakt in the NY Times Upshot Oct 9, 2019, “more singles than home runs”). One of the big goals was to substitute “value” for “volume”. Paying for volume, the number of patients seen, was the accepted way to pay doctors. But what does paying for value mean? This whole issue is reviewed by Dr. Don McCanne in his “Quote of the Day” for March 17, 2021 “Policy community hung up on ‘volume to value’”. Dr. McCanne reviews the recent article “The Future of Value-Based Payment: A Roadmap to 2030” from the University of Pennsylvania on the topic, but in his comments he notes that

“All health care has “volume” – time, effort and resources devoted to health care. Volume varies tremendously depending on the clinical situation. Think of management of a common cold as opposed to management of severe multiple injuries in an accident. Can payment schemes ignore volume? Of course not. Volume is built into the problem.”

Here is a volume/value solution that I have discussed before but will now say clearly: Revise the way that physicians (and other providers) are paid so that family physicians and other primary care doctors make at least as much as those providing subspecialty care. This is the third step to add to universal health coverage and investment in public health. When I go to a shoulder orthopedist for the pain in my shoulder, that is the ONLY PROBLEM they deal with. Not BP, not abdominal pain, not my cold -- not even the arthritis in my knees.  My PCP would deal with every problem on my – and all their patients’ -- problem list (to greater or less extent, depending upon severity and acuity), and thus rarely has enough time for any on person. If you go to the cardiologist, and mention that you have knee pain, they say "I don't do knees; here is a referral to the orthopedist". And you go to the orthopedist, they make a recommendation, you come back to the cardiologist who says "I don't do knees; whatever they said". So, for the subspecialist, referral is a time saver.

But if you come to a PC doc and say your knee hurts, they make some diagnostic and treatment suggestions. After examining your knee, maybe ordering imaging and lab, and thinking about it, if they think it might need surgery, they might refer you to the orthopedist. Then you go and the ortho says "maybe surgery", so you come back and ask your PC doc’s opinion, so they read the whole consult and review the films and think about it and discuss it with you. Result: referral for a PC doc makes MORE work.

And they get paid less.

PC docs need more time with everyone, and thus fewer patients each day/week/year. How much money should they make? I don't care, pick a number, but it should be able to be earned by seeing no more than half the number of visits that they currently do. People's complaint is ALWAYS about not having enough time with the doctor.  

So, increase funding for public health, develop a universal single-payer health insurance system, and pay PC docs at least as much per hour or patient as the highest-paid subspecialist in the outpatient setting. 

Now we begin to have “value”!

Why can't the US have health coverage for everyone? We CAN!

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.