By Drs. James G. Kahn and Elliot Marseille
The Hill, July 17, 2019
The discussion of “Medicare for all” in June’s two Democratic primary debates was both gratifying and confusing. While it was heartening to see agreement on the principle of universal health care as a human right, the debate format eliminated any opportunity for nuance.
That’s why we’re clarifying seven critical issues raised in the debates, and which will likely return during the campaign. Full disclosure: We support Medicare for all and we think that with a clear understanding of the facts, most people will too.
1. What is Medicare for all?
It’s a system with a single, public, nonprofit health insurer, instead of the dozens of private and public insurers we have now. It is not “government-run health care.” It is “government-run health insurance.” Like with Medicare today, health care would be provided by independent doctors and hospitals.
Everyone would be covered for life by a single comprehensive benefit package and would choose their own doctors. Private insurance premiums and out-of-pocket costs would disappear, replaced by taxes that are fair and progressive (richer people pay more). Simplified insurance rules and billing would reduce paperwork costs while negotiations would reduce drug prices. Overall, we would save money while covering everyone.
2. What is a Medicare expansion, as opposed to Medicare for all?
Several candidates (e.g., Michael Bennet and Pete Buttigieg) mentioned a public option, such as a Medicare buy-in. A public option could be offered on state health insurance exchanges, providing what might appear to be a cheaper alternative to private insurance. But it won’t solve our problems. A buy-in would leave the complicated multi-payer system in place, so the opportunities for savings on paperwork and pharmaceuticals would disappear. Moreover, the health insurance industry would use every tactic it knows to push the sickest people into the public option, jeopardizing the financial stability of the program.
3. How do you define “working” when it comes to health care?
Rep. John Delaney (D-Md.) said, let’s “keep what’s working” in our current system. What does that mean? Today, millions of Americans remain uninsured or underinsured — with exorbitant deductibles and out-of-pocket costs on top of their ever-rising insurance premiums.
Medical bankruptcy is common, even among the insured — as Sen. Elizabeth Warren (D-Mass.) noted. And people with employer-sponsored private insurance? They lack health-care security. If they lose their job, they lose their insurance. If “working” means decent and reliable coverage, private health insurance is definitely not cutting it.
4. Which health-care choices really matter?
Beto O’Rourke said “Choice is fundamental” as an argument to retain commercial insurance. Yet it is our choice of doctor (not insurance company) that is fundamental to our care and that’s exactly the freedom that commercial insurance denies us — for profit.
5. What do we mean by private insurance under Medicare for all?
When asked, “Who would get rid of private insurance?” Bernie Sanders, Warren, Bill de Blasio, and Kamala Harris raised their hands. Harris later clarified that she wouldn’t want to abolish private insurance altogether. She has a point: Medicare for all could co-exist with private insurance for supplemental services, like fancier hospital rooms, or alternative therapies. However, private insurance for core medical benefits would be unnecessary. In fact, keeping it would undercut the savings we could enjoy from reducing insurance complexity and pharmaceutical prices.
6. What’s a “glide path?”
Buttigieg endorsed a “glide path,” that is, taking intermediate steps to Medicare for all. This makes sense if the timeline is short and the steps are direct. For example, filling in Medicare’s existing coverage gaps and adding all 50-65 year-olds would be excellent first steps. Alternatively, we could move quickly to help everyone suffering today. It only took about a year to roll out Medicare in 1966, without the use of the Internet or computers.
7. How will doctors and hospitals fare under Medicare for all?
Delaney suggested that if hospitals were paid Medicare reimbursement rates, they’d go bankrupt. This is a misrepresentation. First, under most Medicare for all plans, hospitals would be paid lump sums to cover operating costs. Second, payments would be negotiated to assure financial viability. Raising the specter of hospital closures is a scare tactic.
While Medicare for all may sound complex, it boils down to this: Everyone would get comprehensive health coverage for less money than we’re spending now. Don’t let the confusing debate rhetoric fool you. It really is that simple.
James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.
By Don McCanne, M.D.
Polls have shown that the majority of the public at large supports Medicare for All, but they also show a poor understanding of the all-important nuances of the single payer model of Medicare for All. Even members of the media do not always grasp the subtle but crucially important features of the model that make it so effective in ensuring affordable, accessible, comprehensive health care for absolutely everyone. Drs. Kahn and Marseille clarify for us some of the important nuances behind the rhetoric.
(A parenthetical comment on the “glide path”: There may be important logistical considerations for phasing in the implementation of a single payer Medicare for All program, but we must be certain that 1) the process is more efficient and effective than implementing the entire program all at once, 2) the transition of phasing out the current fragmented system while phasing in single payer does not result in precarious difficulties in winding down operations while simultaneously providing essential services to those still in transition, 3) any delay is based on crucial policy considerations rather than the politics of ideology, and 4) most important, the entire transition needs to be precisely specified in the original enabling legislation rather than merely defining the first steps with the intent of crafting later legislation for additional incremental steps in the glide path to reform. Half a century ago, Medicare for our retired population was to be the first step toward a Medicare program for all, but we never progressed beyond the first increment of including individuals with long-term disabilities and chronic kidney disease. We do not want to make that mistake again. If a glide path proves to be beneficial, it is imperative that it includes the landing lest we end up with another disaster on our hands.)
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