Don’t believe the critics. Medicare for All is the most realistic way to win universal, equitable health care.
By Adam Gaffney, M.D.
Jacobin, August 10, 2017
Fresh off a victory against Trumpcare, health care activists are now looking hopefully towards the future. Already there has been significant progress: within the Democratic Party “Medicare for All” has now achieved a level of support and enthusiasm unprecedented in recent memory.
Yet even as a broad spectrum of progressives coalesces around the cause, others are warning that we should be pressing on the brakes, not the throttle. Joshua Holland penned a piece in the Nation making this case just last week, and Paul Krugman made many similar points in his New York Times column on Monday.
Both argue that single payer should not be a “litmus test” for progressive candidates. They’re sorely mistaken.
Let’s begin with Holland’s arguments as to why Medicare for All may not be the best solution to our health care woes. Holland opens by asserting that while advocates want to use Medicare as the model for single payer universal health care, “Medicare isn’t a single-payer system in the sense that people usually think of it.” After all, he correctly notes, Medicare is partially privatized (via Medicare Advantage plans run by private insurers, as well as in the privatized design of its drug benefit). In addition, because Medicare imposes out-of-pocket expenses on enrollees (for example, co-payments and deductibles) and fails to cover some services, many enrollees purchase supplementary coverage (“Medigap” plans).
“The array of options,” Holland writes, “can be bewildering — it’s a far cry from the simplicity that single-payer systems promise.”
Indeed it is! Which is precisely why prominent single-payer proposals discard these flawed elements. Medicare Advantage primarily functions as a siphon from the public purse to insurance company coffers, and Medicare’s out-of-pocket payments squeeze many seniors. Both are unnecessary. Both should be nixed.
There seems to be some confusion here between what we might call “Currently Existing Medicare for All,” which basically nobody is proposing, and what advocates mean when they speak of “Medicare for All.” But there shouldn’t be: you don’t have to read Conyers’s bill to know that its title is not the “Medicare-for-All Act,” but rather the “Expanded and Improved Medicare-for-All Act.” Holland clearly understands this (he mentions later in his piece that Conyers’s legislation lacks cost-sharing and includes comprehensive benefits), but for the most part he fails to incorporate it into his analysis, leading him to erroneous conclusions.
Consider, for instance, a second point that Holland and Krugman raise: the disruptive impact that single payer could have for those who are already insured through their employer. Krugman believes that problems might arise when the “156 million people who currently get insurance through their employers, and are largely satisfied with their coverage,” switch to single payer. Holland is even more fretful about the political impact of such “loss aversion,” arguing that the portion of the population that enjoys decent employer-sponsored plans may not be thrilled at the idea of being shepherded into Medicare.
“Many employer-provided policies cover more than Medicare does,” he notes, “so a lot of people would objectively lose out in the deal.”
But would they? Again: all major single-payer proposals go beyond Medicare, eliminating cost-sharing and covering a more comprehensive array of health care benefits.
What differentiates the small-bore approaches that Holland and Krugman support from the deeper reform that single-payer advocates propose is that the latter is designed to improve health care for everybody, not just to make sure the uninsured get some form of coverage. After all, despite the talk about people wanting to keep their good employer-sponsored plans, in 2016 29 percent of covered workers had a high-deductible health plan (up from 4 percent in 2006), while the dollar value of workers’ deductibles has shot up by 300 percent since 2006.
Workers also often face copayments and coinsurance (a percent of the cost of the health care service paid out of pocket) for doctors’ visits, hospitalizations, tests, and drugs. And such payments are generally much higher under the non-group private plans purchased on or off the Obamacare exchanges. Many also have to deal with shifting — and often narrow — networks of doctors and hospitals, to the great detriment of doctor-patient relationships and continuity of care, not to mention choice and equal access.
In short, Holland’s point about “loss aversion” misses the mark by a mile: who would resent exchanging a limited network, high-deductible private insurance plan for a public plan that provided first-dollar comprehensive coverage without networks, and which could never be taken away?
Holland doubles down on this point, however, and brings up a related concern. He suggests that because some doctors might not take part in the national health program, “we couldn’t even promise that if you like your physician you can keep seeing him or her.” Yet a single-payer system would be the only game in town: while a tiny percentage of physicians might cater to the rich with boutique concierge practices, we can safely predict that the vast majority of physicians would participate in the national health program.
Why? Well, consider that even today (when there are alternative forms of insurance), some 93 percent of primary care doctors who see adults accept Medicare — essentially the same percent as those who accept private insurance. This rate would presumably be even higher under Medicare for All. Canadian physicians, after all, do quite well under the country’s single-payer system. And to ensure the same held true in the US, we could subsidize the educational costs of health care workers who participate in the national health program, as the latest proposal from Physicians for a National Health Program recommends.
Holland is on firmer ground when he moves to the issue of overall health care spending. While single payer would produce administrative savings, he’s right to note that we can’t reverse history: implementing Medicare for All wouldn’t suddenly bring US health care expenditures in line with those of single-payer countries. But so what? It doesn’t need to.
International examples strongly indicate that, at the very least, single payer should be no more expensive (in terms of overall national health spending) than what we have today. And what single-payer advocates are really arguing is not that we will soon be spending the same percentage of GDP on health care as Canada, but rather that by eliminating the enormous waste of the extractive and useless private health insurance apparatus and slashing drug prices (among other efficiencies), we will generate the savings we need to create the system we want: one in which everybody has first dollar coverage and equitable health care access.
But might there be a third, less disruptive, alternative to the status quo and single payer?
On the one hand, many other systems don’t actually do the sorts of things that single-payer advocates are calling for in the US (this is Holland’s point); on the other, single payer is not the only international example worth considering (a point that both Holland and Krugman stress).
Holland, for instance, notes that US single-payer proposals go beyond Canadian Medicare, which doesn’t cover prescription drugs or dental and eye care, causing many to buy supplementary insurance plans. This is true, yet it only reinforces the argument for a better single-payer system here. Canadian Medicare should cover those things; the fact that it doesn’t is one flaw of that overall superior system. One study, for instance, found that among eleven high-income nations, Canada was surpassed only by the US in the proportion of residents aged fifty-five and over who didn’t take medications because of cost. Not surprisingly, progressives in Canada are pushing for universal drug coverage.
Pointing out other single-payer systems’ shortcomings, then, is hardly a knock against a proposal for a more comprehensive single-payer system here.
In other respects, however, it’s not clear that single-payer advocates are asking for much more. Holland asserts, for instance, that “no other health care system offers such expansive benefits” as Conyers’s Medicare-for-All bill, which eliminates out-of-pocket costs for all health care services. While it is true that most systems have some form of (rather limited) cost-sharing, this is both unnecessary, and not universally the case, as Holland seems to suggest. There are no co-payments (much less deductibles) for doctor visits or hospitalizations in Canada or the United Kingdom. And in Northern Ireland, Scotland, and Wales, prescription drugs are free for all.
The second and larger point that Krugman and Holland stress is that some European nations have more of a mixed private-public model, and thus that single payer is not the only option. “There are lots of ways to skin this cat,” Holland writes. But while it is true that every health system is something of a snowflake, the best European examples share some key similarities. What we call single payer is basically national health insurance, which despite some (mostly unnecessary) organizational heterogeneity and complexities is what basically exists in countries like Australia, Canada, and (for the most part) France. The United Kingdom also has a single-payer system, albeit coupled with a more socialized delivery system: nationalized hospitals.
Other nations admittedly have more complex systems. Making sense of the basic nature of Germany’s system, for instance, has been called something of a “puzzle,” yet its not-for-profit system of highly regulated statutory sickness funds — jointly run by labor and employers — barely resembles the Obamacare system, and might better be seen as a decentralized form of national health insurance.
Then there is the Dutch example, often cited by those who find the incremental road appealing. However, though it is true that in 2006 the Dutch transitioned toward a somewhat more market-oriented, Switzerland-like, “managed competition” model, its system remains tightly regulated well beyond the Obamacare system; more importantly, evidence suggests that the managed competition makeover wasn’t particularly helpful, and indeed may have had a dubious impact in terms of equity and efficiency. As Kieke Okma, Theodore Marmor, and Jonathan Oberlander concluded in the New England Journal of Medicine in 2011:
The Dutch experience provides a cautionary tale about the place of private insurance competition…The idea that the Dutch reforms provide a successful model for US Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in US health care reform debates.
Two final, key points: first, it is not clear that transitioning to a more complicated public-private model that turns insurers into nonprofit, highly regulated funds will be more politically feasible in the US than going all the way to national health insurance. The industry will fight both to the death. And second, hybrid models — like those in the Netherlands and Switzerland — are less efficient than fully public ones. If first-dollar comprehensive universal health care under single-payer produces some new costs (and it will), achieving such a system would only be that much more expensive, and perhaps truly unaffordable, when implemented within the framework — and subordinated to the interests of — the bloated private insurance industry.
In reality, neither Holland nor Krugman are recommending we adopt the Dutch model. What is it, then, that the Medicare-for-All naysayers are actually promoting in place of single payer?
Krugman mentions that the public option should be strongly considered, but that otherwise progressives should basically abandon health care reform and move on to other things. Holland, for his part, more explicitly discusses an ambitious public-option-like program drawn from political scientist Jacob Hacker, which he calls “Medicare-for-All-Who-Need-It.” But here’s the thing about both: they would not, if achieved, deliver the benefits that Medicare-for-All proponents are fighting for.
This is not simply about different ways to skin a given cat, as Holland writes, but about which particular cat we intend to skin (with due apologies to cat lovers). Single-payer advocates’ aims are admittedly ambitious, yet also quite clear: we want to eliminate uninsurance and underinsurance, and create a right to equitable, comprehensive, first-dollar health care for everyone in the country, as soon as possible. And our proposals (e.g., the Conyers bill) would achieve those goals if implemented.
The more incremental reform proposals wouldn’t. As I’ve written recently, adding a public option to the Affordable Care Act’s marketplaces would — according to the Congressional Budget Office — fail to even reduce the number of uninsured. And the admittedly far more robust Medicare for Some that Holland seems to favor would — even if it nearly eliminated uninsurance (hardly a certainty) — fail to remedy the US health care system’s other fundamental flaws.
What would it do for the growing ranks of the underinsured, including workers with employer plans who are being squeezed by rising deductibles and soaring drug costs? What would it do for those insured under Medicare, who lack access to important services like dental care, or who face cost-sharing that takes a sledgehammer to their finances? What would it do for drug prices on the national level? And how would it create the system-wide savings needed to achieve the comprehensive, first-dollar system single-payer proponents are struggling for?
Critiques like Holland and Krugman’s therefore crumble at the most basic level. With Improved and Expanded Medicare for All, we are aiming to improve health care for all — which is precisely what makes our project so politically potent, and hence possible: it is a universal program that, by giving something to nearly everybody, is designed to bring together the admittedly enormous coalition required to win it.
Those with Medicaid would retain their (often) broad benefits, but would enjoy equity of access. They’d be able to go to the same doctors and hospitals as everybody else, and perhaps more importantly, not worry about losing coverage as soon as they receive a tiny raise. Those insured by their employers (or via the Obamacare exchanges) would see their deductibles melt away, their networks expand, and the fear of losing coverage disappear forever. Those with Medicare could stop using scant household funds to buy supplementary “Medigap” plans, and would have their teeth cared for. And none of us would need to worry about getting dropped from our health coverage — or facing a medical bill, much less a medical bankruptcy — until the end of our days.
Sound good? It would be. Seem bold? Absolutely, but other nations show that it’s possible. Should Medicare for All be a litmus test? Damn right.
Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.