Medicare for All? ‘Crazy,’ ‘Socialized’ and Unlikely

By Katharine Q. Seelye
Prescriptions Blog
The New York Times
September 19, 2009

Jonathan S. Skinner, an economics professor at Dartmouth, said there would be both positive and negative effects from expanding Medicare to all.

“The best thing about expanding Medicare is we can cover everybody with one sweep of the pen and cut administrative costs substantially,” he said.

But, he said, it would probably require a tripling in payroll taxes just to pay hospitals alone. And it would do nothing to control costs, Mr. Skinner said.

“Medicare is dysfunctional,” he said. “It provides the wrong incentives to doctors. This would be extending that dysfunctionality to the entire population.”

Expanding Medicare, he said, is “the cotton candy solution: it feels really good, but after a while, your stomach starts to go ‘ewwww.’ ”


Fostering Accountable Health Care: Moving Forward In Medicare

By Elliott S. Fisher, Mark B. McClellan, John Bertko, Steven M. Lieberman, Julie J. Lee, Julie L. Lewis and Jonathan S. Skinner
Health Affairs
January 27, 2009

To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and “shared savings” payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible.

Several readers found fault with Katharine Seelye’s dismissal of “Medicare for all” single payer reform as being too complicated, imposing a big tax increase on the middle class, and driving doctors and hospitals out of business because of low reimbursement rates. She also quoted Stuart Altman as saying it would be too disruptive, and Robert Moffit as saying that it would mean too much government intrusion.

Too complicated? A single payer system is much simpler and more efficient than the fragmented multi-payer system under consideration by Congress. Big tax increase? Moving from individual insurance premiums to a single taxpayer-financed risk pool would not only be more efficient, but it would finally make the way we pay for health care much more equitable. Driving doctors and hospitals out of business because of rates? The stewards of a single payer system would never establish a deficient pricing system that would shut down our health care delivery system.

Disruptive? Our overpriced and underperforming health care system screams out for disruption. Too much government intrusion? Most other industrialized nations have demonstrated that more government involvement than we have is an essential ingredient in achieving a better performing system at a lower cost.

Jonathan Skinner, whose comments were selected from Seelye’s article, is part of the Dartmouth group that demonstrated large variations in health care spending that do not correlate with quality and outcomes. Medicare’s fee-for-service payment system is thought to contribute to this inconsistency by rewarding greater frequency and intensity of services while ignoring quality.

It is great that Skinner and his colleagues, and others as well, are looking at options that might provide us with greater value in our health care purchasing. It is ironic, however, that they propose “fostering accountable health care in Medicare” while he states that the “cotton candy solution” of expanding Medicare would make your stomach go “ewww.”

An improved Medicare that covered everyone would provide the financing environment that would ensure the best health care value attainable. There’s no “ewww” there.