Universal health coverage would save money. And lives. And make life a lot better for people.

Two recent Gallup polls confirm long-standing problems with the US health system. Americans Sour on U.S. Healthcare Quality finds that 

For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% -- a new high -- calling it “poor.” 

It is important to read that carefully; it does not say that “for the first time in two decades, Americans find problems with U.S. healthcare”. It says that for the first time fewer than half rate it as “good” or “excellent”. And “a new high”, 21%, say it is poor. This is very significant because the opinion one has about healthcare varies tremendously depending on whether one has needed it or not. If you, and your family, have been healthy, and have rarely if at all needed anything other than, perhaps, immunizations or checkups, then you are likely to perceive the system as better. Even then, you probably had some difficulty getting an appointment, getting through to find out the results of any tests you had, and difficulty communicating in general. And it likely cost a lot. If you were just a little sick, it can be irritating, frustrating, and even risk your health to some degree. But if you are really sick, and especially if you need to be in the hospital, it is very unlikely that your experience was even “fair”.

This is something that a lot of people, and a lot of pundits miss. When you don’t need health care, everything is fine, and your insurance is good and pays for all of the nothing you use; indeed even being uninsured is fine. It is just that pesky problem of it not being fine when you need it. Like anything; you don’t regret not having a down coat on a balmy Spring day, or an umbrella when it is dry. There is an old story about a traveler coming across someone whose roof is leaking in the rain. The traveler asks why he doesn’t fix it. The man responds that when it is raining it is too wet to get up on the roof, and when it isn’t, “my roof is as dry as anyone’s.” This is fine as a joke, but not as  healthcare strategy. When you or a family member is in a car accident, or gets a cancer diagnosis, or needs major (or even minor) surgery, or your newborn needs to be in the intensive care unit, is not the time to start to think about your health coverage.

And, yet, that is what many people do, are forced to do, to depend upon hope and prayer. While for some this could be in part an issue of distorted priorities – health insurance is expensive and I could be buying a nicer house or a bass boat –this is not the usual reason. It is more often “health insurance is expensive and I need to pay the rent and buy food and put shoes on my children’s feet”. And if their budget allows them to actually buy health insurance, it tends to naturally be the one that the buyer can afford – and is often inadequate, and have high patient responsibility (co-pays, maximums, and other costs). Thus “having health insurance” deludes you (and many pundits and policy makers) into thinking that you have taken care of this issue. Until you need it.

Which brings us to the results of another Gallup poll, released at the same time, “Record High in U.S. Put Off Medical Care Due to Cost in 2022”. “The latest reading, from Gallup’s annual Health and Healthcare poll conducted Nov. 9-Dec. 2, is the highest by five points and marks the sharpest year-over-year increase to date.” Not a surprise given the information above. You can put off going to the doctor for a checkup, or a cold, or a vaccine, or even for treatment for a significant chronic disease like diabetes, high blood pressure, heart disease – at least if is not bothering you too much – but it is not very wise, since ignoring such conditions is one way to get you really sick, and into the hospital, and maybe into intensive care, and maybe, even, die. However, since we don’t have a universal health program in the US, too many people simply cannot afford to get healthcare, especially anything that is costly. I am tempted to say that there is a price list, and, like buying a car or a house or a coat, you shop within your means. Except, of course, there is no price list, and you hardly ever know what a medical procedure will cost. And there are often no good alternatives to the expensive treatment; in this way it is definitely not like buying a perfectly functional, if less fancy, car.

A third important article was published in June 2022 in the Proceedings of the National Academy of Sciences USA. “Universal healthcare as pandemic preparedness: The lives and costs that could have been saved during the COVID-19 pandemic”  by Galvani, Parpia, Pandey, and Fitzpatrick, estimates that during the pandemic a universal healthcare system would have saved 212,000 lives and $105.6B from COVID alone, in 2020 alone. This would have risen to about 338,000 lives through March 2022, as reported on in the Scientific American, and would have been on top of another $438B saved from other causes besides COVID. That is a lot of money. And a lot of lives. More than 100 times the number of lives lost in the World Trade Center attack. And (see the polls from Gallup) that is not counting the people who didn’t die, but could have. Who lost their health, their ability to work, their life savings, their ability to provide for their families.

So what is this “Universal Healthcare” thing? Some kind of pie-in-the-sky dream of liberals that would bankrupt the US? No, it is what they have in every other wealthy country in the world, and many that are not so wealthy. Those countries that don’t consider health and healthcare to be a consumer luxury, that consider it to be about people’s health rather than something for the private sector to profit from. Remember, that $105,600,000,000, and that $438,000,000,000 (2020 alone) is not going into the garbage. It is going to health insurance companies, and health care providers (by which we mean not only – or even mainly – doctors, but rather hospitals and “health systems”) and their suppliers, especially drug companies. This is detailed in the latest publication on this topic (regularly updated, and rarely improving) from the Commonwealth Fund. “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes” shows that the US is the only wealthy country that does not guarantee health care coverage to all its people, and still spends 2-4 times as much as those other countries. The money goes, of course, to private profit. There is a name for this: corruption and graft. And words for it. Mostly obscene.

So why don’t we do something about it? We have tried – President Truman tried to get a national health insurance system in 1948. Defeated, sadly, with support from labor unions who thought it would undermine their success in getting health insurance through negotiations with employers (there’s a quaint memory). Medicare, a national health insurance system for seniors and the disabled, was passed in 1965 under President Johnson. So was Medicaid, a state/federal partnership to provide coverage for many (but certainly not all!) poor people. In 2010, under President Obama, ACA (Obamacare) was passed, which extended health coverage to many (but certainly not all!) of those left out, who were unable to afford individual health coverage but were not poor enough to get Medicaid (and in most states that is desperately poor!).  But nothing comprehensive, nothing that covers everyone, nothing that guarantees you won’t be broke and in debt at the end. Nothing that resembles the systems in any other OECD (i.e., wealthy) country.  Why?

Because private corporations make lots of money, from you, and from your employer, and from the government, and very much do not want that to go away. Indeed, as I discussed recently (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, January 20, 2023), the private sector is expanding its leech-like sucking of public funds through privatization of Medicare by programs like Medicare Advantage and ACO/REACH. And are willing to spend some portion of that huge amount of money on lobbying – and making contributions to – members of Congress, to make sure that their profits are maintained at the expense of the health and lives of the American people, not to mention their money.

It is  that simple. The health and lives of people vs. the profit of corporations. Don’t be fooled by liars or obfuscators. It is time to end this incredibly expensive boondoggle that costs the lives and health of so many of us. Write your Congresspeople and demand Medicare for All, or any form of completely universal healthcare, now.

Or sooner.

In Europe, health care does not bankrupt people. And universal coverage means they get the care they need.

A recent note from a friend of a friend:

‘Here we are in the Pyrenees foothills outside Perpignan [France]. An hour away from the closest ER. X was in the hospital with afib [atrial fibrillation, a heart rhythm disturbance] before we left for France in July and I’m worried about being so isolated. So in Sept he seemed disoriented for a few moments and I was worried so called the French version of 911. I just told them what was going on and they connected me directly with a doctor. They sent an ambulance. The EMTs thought he was OK after checking. But just in case, they SENT A HELICOPTER WITH A DOCTOR from Perpignan. Who also thought he was probably OK. But to be safe they took him by helicopter to Perpignan, arriving in nine minutes. They kept him overnight and let him go the next morning. He’s fine. I had to call them three weeks later to ask for a bill. They emailed it to me. It was itemized: ER, helicopter, two cardiologists, several imaging tests, overnight stay. Total price (for the uninsured): 249 euros.’

Wow! How much is a Euro? Must be like 10, or 100, times as much as a dollar, right? Um, no. Actually, with its recent fall the Euro is just about exactly $1. So $250 for all that? Unbelievable! In fact, if the Euro was worth $100, it would be $25,000, which would still be a lot less than the cost would have been in the US. If you could get that kind of care!

Indeed, that was the situation for this same family earlier…

‘Five years ago X had another chronic problem which has mercifully since been totally fixed. We came here, it started up, and we ended up with five ER admissions, six weeks in private rooms, 3 specialists, transfusions, intensive care, many tests, IV antibiotics etc etc etc. Total bill: about 20,000 euros over 6 weeks. Then back to [hometown in US], one night at [university hospital]: same price.’

What is going on here? It really is unbelievable! Except what is unbelievable, to people in France, or most of Europe, or most countries in the wealthier part of the world, is that we would find their out-of-pocket cost of care surprising. Everyone thinks, to some degree, that what they know, what their world consists of, is pretty much normative, that it is the same for kind of the same people everywhere. In fact, even when they intellectually know that it is not true, it is still one’s instinctive reaction, to think that what is normal for you is normal. Luckily for the French, what is normal for us in the US, in regard to the cost of healthcare, is not normal for them. And, of course, unluckily for us. And this is not a recent change.  It wasn’t even new back on January 21, 2012, almost 11 years ago, when I wrote ‘One thing to NOT worry about: paying for health care -- in France. Or for decades before that. In that piece, I wrote about going to see the film Le Havre and noted that in it a really poor person spends weeks in the hospital and the one thing no one is worried about is the cost. This could never be true in the US.

Doesn’t this upset you? Don’t you think something is wrong here? What is going on????

Sorry.  Of course it does. But, you know, it must be costing someone a lot of money, even in France, or wherever. All that health care, all those hospitalizations, all those tests, do not come cheap.

No, they don’t. But they don’t have to be so expensive. There is incredible markup on the bills and amount paid in the US. Not that anyone actually knows what the price is, or that there is any consistency to it.  US hospitals do have a Master Price List (like “one gall bladder surgery, $X) but it rarely is what is either billed or paid. These hospitals have deals cut with large insurers on how much they will be charged, and pay, on behalf of their customers. Medicare, the government insurance system for the aged and disabled, sets its own rates as to what it will pay (and the private insurance rates are usually expressed in “multiples of Medicare”). Really the only people who might be charged the “list price” are those who are uninsured and poor, those least likely to be able to pay it – although very few of us could pay those amounts! The couple who wrote about their experience in France is obviously well enough off to have spent that time in France, and to have paid their bill, but just being reasonably well off is far from sufficient to be able to pay hospital bills out of pocket.

Let us be entirely clear and simple: The reason US health care costs so much is profit. It is that everyone, everywhere along the line, is taking a cut. The insurance companies, right from the start, huge profits (and salaries to their executives). Hospital systems, huge markups (and salaries to their executives). Pharmaceutical companies, huge markups (and salaries to their executives). Doctors also, especially in some specialties. I could give lots of examples of those specialties with the highest income/work ratios. It is not because we use “too much health care” – indeed, it is really unlikely that any of us (unless a billionaire or a head of state) could have gotten the care that X did in France, and they did that just “routinely”, because it was what they thought was medically the right thing to do.

That, of course, is the other part of this story. It is not just that the charges and costs to the individual were so much less than what they would have been in the US. As a physician friend pointed out “The dollars and cents issue is important. But freeing the medical community to just do the right thing is immeasurable.” Think about that. At each stage, from the person’s wife calling French 911, to the EMTs who came, to the doctors who decided to airlift him to the city, to those who cared for him in the hospital, the decisions that they made were medical, what, in their judgement, was the best for the health of the person/patient. At no point did the cost of the care enter into their decision. Well, I take that back. It may have. But what did not enter the decision was “what kind of coverage does this particular person have? Does it pay enough? Does it cover what we want to do? Have they met their deductible? Can they afford the copay?” This is what you would want for your own health care, and it is absolutely what doctors and other health professionals want to be able to do. Once there was a joke (what today would be a meme) that before doing a procedure the doctor would do a “wallet biopsy”. Today, it is more often the hospital, and it is more likely an “insurance biopsy”. This is crazy.  It is crazy. It is unacceptable. And more important, it is unnecessary.

And the cost of health care per capita is much LESS in France, just as the quality of care is higher (as I cited from the Commonwealth Foundation in my last blog post, Premiums are up, people are dying and insurance companies are making out like the bandits they are, October 25, 2022). Indeed, it is less than half the per capita cost in the US. And in France, that includes everyone; no one is without coverage.

Of course, not foreigners, like those visitors from the US, who had to pay their whole bill themselves with no insurance.  All $250 of it.

"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  

A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.