Medicare for All, including the Stranger

By Pippa Abston, M.D., Ph.D., F.A.A.P.

It’s easy to view Medicare for All and Strangers without paperwork through the lens of faith.  “When I was sick… you visited me.”  No mention of citizenship here! Maybe Jesus would say we are all citizens of the Kingdom.  We can legislate morality—we do it all the time.  What we can’t legislate is God. We can’t legislate Love.  The politics of healthcare, minus God/Love, is a little more complicated.  Here’s my attempt to reconcile Medicare for All, including the Stranger, with my working politics.

I’m not going to repeat the reasons national health insurance would be a common good. The short version:  providing publicly funded health insurance to everyone here is the best way to improve the cost-effectiveness and quality of our healthcare system.  If you don’t agree with this, I’m going to keep arguing with you!  Bring it on.  My daddy didn’t call me stubborn for nothing.

However, I committed recently to work towards positions that don’t restrict the freedom of any particular person unnecessarily.  To do this, I tried out three “me” perspectives—patients who don’t want to use national health insurance, doctors who don’t want to be paid with it, and insurance company executives.

I’ll be an insurance company executive first, because the other perspectives build on that.  Had to put on some fancier clothes, right off the bat!  As this person, I don’t see how it is justice for the State (We the People) to take my job IF not completely necessary to protect the liberty of others to access the common good of national health insurance.  The argument of single payer advocates has been that as long as I am around, public insurance won’t work.   I can think of one way it would.  Don’t allow any elected/ appointed official or public employee to keep their jobs if they buy my product for themselves or their dependents.  Don’t give any State funding to a business or person that buys my product or employs anyone who does.  Make all campaign financing public only, so that I can’t monetarily influence politicians.  Don’t pay any doctor or hospital out of public money if they also take my money. And stop spending any taxpayer money regulating/ monitoring my business.  Caveat emptor. If I still get in the way of public insurance, I guess I’ll have to get another job.

Next I’ll be a person who doesn’t want to use the national health insurance I help pay for.  Fair enough—I already pay for public schools my kids don’t use. No vouchers, BTW–vouchers don’t square with a philosophy that we all have to contribute to majority-determined common goods. If private insurance is illegal, I can pay medical costs out of pocket if I want to.  If it is legal, I can buy it except under the conditions above.  I am free to leave public employment if I don’t like those rules.

Finally, I will be a doctor who doesn’t want to take national health insurance payment.  No problem—I don’t have to.  There will be some rich folks out there who want to pay me as a concierge or buy high-priced private insurance.  I’m worried about having to compete for the few who will do that, but if it doesn’t work I can switch to the public plan.

Whew, tired of the fancy clothes!  Back in my blue jeans.  Leaving the door open for a few die-hard market-based medicine folks isn’t going to affect us too much.  Think about it—when have we ever been able to keep the rich from getting extra?  It isn’t worth our time to bother with that stuff. We can make restrictions so stringent it wouldn’t rise to the level of a worrisome two-tier system.

Finally, why provide public health insurance to the Strangers among us? For the same reasons, moral and financial, we should provide it to citizens.  It is more cost-effective to cover folks on the front end, in one large risk pool, than to pay for uncompensated care later. As for getting fair contribution, two-thirds of undocumented immigrants already have payroll taxes deducted with fake social security numbers.  We could do even better by quickly issuing temporary guest visas, while we figure out a better way to manage our immigration process and borders.  The only reason not to include everyone?  Plain old meanness.