By Donald M. Berwick, M.D.
USA Today, October 22, 2019
With costs rising painfully, insurance companies denying care and nearly 30 million people still uninsured, America desperately needs an honest health policy discussion. That’s why it has been so disappointing over the past several weeks to watch multiple candidates parrot right-wing attacks on “Medicare for All,” like claiming that it will greatly increase spending on health care or ringing alarms about raising taxes on the middle class.
The truth is the opposite: Medicare for All would sharply reduce overall spending on health care. It can be thoughtfully designed to reduce total costs for the vast majority of American families, while improving the quality of the care they get.
Over my career, I have witnessed the problems with our health care system firsthand. As a pediatrician, I have seen how our fragmented, expensive system hurts children and families. As a researcher at Harvard Medical School, I have studied the causes of waste and overspending in our system. And as President Barack Obama’s head of the Centers for Medicare and Medicaid Services, I led the existing Medicare system and helped stand up Obamacare.
Best fix for a patchwork health system
What I saw convinced me that the Affordable Care Act was an essential step forward. But covering all Americans through a single-payer, federal insurance program would now be a wiser path. President Obama has said it himself: It is now time for “good new ideas like Medicare for All.”
The case for Medicare for All is simple. It would cover everyone — period. Done right, it would lower costs, a lot, while letting us leverage health care dollars to respond to public health crises like the opioid epidemic, invest in disease prevention and modernize care delivery with telemedicine. And it would be simpler, easing the onerous burdens of billing for doctors, endless paperwork for all health care professionals, and navigating the confusing coverage system for patients and families. Compared with some candidates’ plans that retain our patchwork of coverage, Medicare for All wins twice: on both simplicity and savings.
Some candidates have attempted to sidestep the cost debate by promising to spend less and accomplish the same goals. These proposals, such as relying on a public option or expanding Medicare Advantage, offering private plans within Medicare, provide too few details to allow real cost comparisons. But it is unlikely they will do as much as Medicare for All would to reduce national health care spending or reduce costs for families.
Sen. Elizabeth Warren of Massachusetts suggested as much when she claimed in the latest Democratic presidential debate that one alternative proposal, “Medicare for All Who Want It,” would really mean “Medicare for All Who Can Afford It.” The reasons are simple. First, these alternative plans retain a costly architecture of private profits and payment complexity. And second, they don’t have the scale of Medicare for All, which is crucial for simplifying billing, improving the quality and safety of care, and removing wasteful spending.
Nearly certain to save trillions
Faced with these facts, opponents of Medicare for All too often revert to myths instead. The first myth is that Medicare for All will necessarily increase health care spending. That’s wrong. The fact is that, without a change, Americans will spend over $45 trillion on health care in the next 10 years. Under Medicare for All, total health care spending would likely be far lower. The cost would depend on many implementation decisions that Vermont Sen. Bernie Sanders’ bill, for example, leaves open for thoughtful exploration, careful choice and adjustments over time: payment rates to hospitals and doctors, content of the benefit package, details of price negotiations with drug companies, design of simplified administration and more.
The costs are largely under our control; they will depend on how we design the new system. If we made wise choices, I regard it as nearly certain that Medicare for All would save trillions of dollars over the decade compared with our projected health care spending.
The second myth is that is Medicare for All must raise taxes on middle-class families. That is misleading. Medicare for All’s cost to families, no matter how it is funded, should be compared with what those same American families will spend on health care if we do nothing. And as things stand now, the trajectory of their health care spending is looking increasingly painful. Sanders at last week’s debate railed against “defending a system which is dysfunctional, which is cruel,” one that leaves tens of millions of people uninsured or underinsured, and contributes to tens of thousands of deaths and bankruptcies each year.
Health care costs are crushing the middle class, taking more and more money straight from the wallets of workers and families. Small businesses simply cannot afford coverage anymore, and governments at all levels know that uncontrolled health care costs crowd out other priorities, like roads, schools and the social safety net. Every “Made in America” product has these sky-high costs built into its price. The average premium for a family of four in 2019 is a staggering $20,576 — a toll that is eating into their wages, while their out-of-pocket costs soar.
Since 2009, premiums have increased 54% and workers’ contributions to premiums have increased 71%, but wages have risen only 26%.
A shift in family costs, not an increase
Framing this debate by fearmongering over “higher taxes” ignores that this money is already coming out of American families’ pockets. Right now, these costs actually amount to a regressive tax that every family pays no matter whether their wage-earner is a CEO or a secretary. We can discuss whether a Medicare for All program that uses our money to fund Medicare instead of financing private insurance companies is a good idea. But it is deeply misleading to pretend that this shift is an increase in family health care costs. It is not.
And no one should buy the myth that Medicare for All represents a “government takeover of health care.” It does not. Medicare for All is about paying for care, not providing it. Not one proposal suggests that health care delivery should become a government function (beyond existing forms like the Veterans Health Administration). It offers Americans, at last, a simple way to assure that they have the coverage they need to see the doctors they want and use the hospitals they choose. Almost all doctors and hospitals would be in Medicare’s network, and no patients would have to check their insurance card to find out whom they can see and at what cost out of pocket.
The country deserves a real debate about health care — not one that misleads Americans about how public financing of health care would affect them. A real debate would show that Medicare for All, though not a perfect solution, is the best option we have to get health care costs and quality back on track, lifting an exhausting burden off American families and businesses.
Dr. Donald M. Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement, is a lecturer and former faculty member at the Harvard Medical School and was administrator of the Centers for Medicare and Medicaid Services in the Obama administration.