By Adam Gaffney, M.D., M.P.H.; David Himmelstein, M.D.; and Steffie Woolhandler, M.D., M.P.H.
Health Affairs Blog, February 16, 2021

For the first time in a quarter century, the Congressional Budget Office (CBO) has undertaken an economic analysis of single-payer health care reform, also known as Medicare for All. The more than 200-page working paper, released last month, includes a rich explanation of methodology together with cost projections for 2030 and will no doubt serve as an important reference for years to come.

The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.

The CBO models costs under five different variants of single payer. The first four envision universal coverage of all services other than long-term care, while the fifth incorporates a large expansion of long-term services and supports (LTSS) for people with disabilities of all ages. The scenarios vary by patient cost sharing and provider payment level. Low cost-sharing has no copays or deductibles for medical services and minimal cost sharing for prescription drugs; under high cost-sharing, patients with incomes above 150 percent of poverty would bear about 7.5 percent of costs out of pocket. Low payment rates to providers would set rates slightly higher than Medicare’s; high rates would be equivalent to the current average of the rates paid by private insurers and government programs. The five variants (or scenarios) are summarized in exhibit 1.

Exhibit 1: Congressional Budget Office’s five single-payer scenarios

Source: Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec.

We discuss below the CBO’s estimates of single payer’s overall effects on national health spending, the implications of the estimates for providers, and the concerns the analysts raise about worsened “provider congestion” under a single-payer health care system. Throughout, we point out instances where the CBO’s assumptions differ from previous, widely publicized analyses, or from provisions included in the Medicare for All legislation currently in Congress.

CBO’s Estimates Of Single Payer’s Effects On National Health Expenditures

The CBO projects that variants 1–4 of single-payer reform would reduce national health expenditures (NHE) despite substantial increases in the use of care triggered by expanded and upgraded coverage. If a vast new program covering LTSS for all US residents were included (scenario 5), the CBO estimates that NHE would rise by 4.4 percent above currently projected spending levels. Exhibit 2 summarizes the CBO’s spending estimates for the three low cost-sharing scenarios, which are similar to the Medicare for All bills in Congress.

Exhibit 2: Congressional Budget Office estimates of effect of single payer on health spending in 2030: low cost-sharing scenarios

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec. Note: “Net change in provider payments” reflects combined effect of rate setting and increased use.

How can the use of care rise even as spending falls? Mostly, according to the CBO, through greater administrative simplicity. As the CBO notes, traditional Medicare’s administrative overhead accounts for approximately 2 percent of its total revenue, compared to the 12 percent overhead of private insurers. Under single payer, the CBO projects, administrative spending would fall accordingly; overall overhead for the Medicare for All system is estimated by the CBO at below 2 percent. As shown in exhibit 2, this translates into around $400 billion annually (more than $1,000 per capita) in savings under all of the single-payer variants.

Of note, these evidence-based projections clash with the analyses by the Urban Institute and the RAND Corporation, which perplexingly assumed much higher administrative overhead under a single-payer system than under the current traditional Medicare program or under universal systems abroad.

Implications For Provider Overhead And Revenue

The CBO appropriately projects substantial administrative savings for providers, again unlike many previous analyses. US hospitals and physicians waste money and time contending with multiple payers, each with its own complex and varying coverage rules and payment procedures, formularies, and so forth. The CBO projects that the share of revenues that hospitals spend on administration would fall from 19 percent at present to 12 percent under single payer; that physicians’ administrative overhead would fall from 15 percent to 9 percent; and that the administrative expenses of other medical providers (for example, dentists, home health agencies, and hospices) would fall from 9 percent to 6 percent. In addition, it estimates that physicians and nurses would spend less time on administrative activities, freeing up 4.8 percent of physicians’ work hours and 18.4 percent of nurses’ work time. These assumptions build on a large evidence base showing high administrative overhead among US health care providers relative to other nations.

The CBO assumes that single payer would allow providers to keep these savings on administration and billing, and use the resources freed up to provide more care. Hence, providers’ administrative savings do not appear as savings in exhibit 2. In effect, the CBO interprets these efficiencies as reductions in providers’ costs that would enable them to deliver a greater quantity of services for a given amount of revenue.

Consequently, the “net change in provider payments” shown in exhibit 2 doesn’t fully account for the extra resources made available to hospitals, doctors, and other providers under Medicare for All. In contrast, exhibits 3 and 4 present our estimates of single payer’s financial impacts on physicians and hospitals, incorporating CBO projections of providers’ savings on administrative spending and physicians’ and nurses’ time.

As exhibit 3 demonstrates, payments to clinicians would rise in all five scenarios according to CBO estimates. We estimate this translates into an additional $39,816–$157,412 in revenue per practicing physician. At the same time, physicians’ practice overhead would shrink under single payer, increasing practices’ take-home income. Such a windfall, in our view, may be excessive, at least for some providers. (Disclosure: The authors are all physicians).

Exhibit 3: Modeling Congressional Budget Office’s low-cost sharing scenario: ramifications for physicians

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO; 2020 Dec. Note: *Based on Association of American Medical Costs estimate of 840,000 practicing physicians in 2030 and the assumption that physician payments account for 77.78 percent of payments in the “Physician and other Clinical Service” category, as they did in 2018 according to the National Health Expenditure Accounts.

For hospitals, the CBO estimates that gross revenue would fall by $187 billion under the “low pay” scenario but rise by $144 billion under the high-payment scenario. Again, these figures do not give the full picture of the impact on hospitals’ bottom lines, given the CBO’s projections that single-payer reform would shrink hospitals’ spending on administration and would also free up substantial amounts of nursing time that is currently devoted to payment-related tasks. The CBO’s estimates suggest that hospitals would save $143 billion to $166 billion on administration and an additional $59 billion on freed-up nursing time, resources that could be redirected to clinical care (exhibit 4). Overall, building on the CBO’s projections, we estimate that hospitals’ clinical funding would change little (rising by $15 billion) under the low-payment scenario or increase substantially, by $369 billion, under the higher-payment one.

Exhibit 4: Modeling Congressional Budget Office’s low cost-sharing scenario: ramifications for hospitals’ revenues and clinical operating budgets

Source: Authors’ analysis of the Congressional Budget Office’s (CBO’s) Single-Payer Health Care Systems Team. How CBO analyzes the costs of proposals for single-payer health care systems that are based on Medicare’s fee-for-service program. Washington (DC): CBO: 2020 Dec. Notes: **Based on the CBO estimate that hospitals’ spending on administration (excluding registered nurse (RN)and licensed practical nurse (LPN) time spent on administration) would be reduced from 19 percent to 12 percent of hospital revenues. ***Based on (1) Bureau of Labor Statistics estimate of number of RNs and LPNs employed in hospitals and average RN and LPN wages in 2019; (2) the assumption that benefit costs equal 20 percent of wages; (3) the assumption that nursing costs would rise at the same rate as overall hospital costs; and (4) CBO’s estimate that RNs and LPNs devote 23 percent of time to administration and that single payer would reduce that time by 80 percent.

The large increase in hospital funding that the CBO projects under the high-payment scenario would, in our view, give an appropriate boost to many struggling rural and safety-net hospitals but would be excessive for hospitals that are currently realizing large annual profits.

Additionally, the fee-for-service hospital financing modeled by the CBO differs from what is envisioned in the Medicare for All bill in the House of Representatives. The House bill proposes paying hospitals, nursing homes, and other institutional providers using “global budgets,” that is, lump sums to cover all of their operating activities. This is the model used by Canada and the US Veterans Health Administration. Global budgeting could allow even greater reductions in administrative spending by eliminating the need for per-patient billing altogether. It would also allow payments to match current operating budgets and facilitate the gradual redistribution of funding among hospitals, directing more resources to communities most in need.

The global budgeting approach, however, would require separate financing of capital expenditures (as in Canada and some European nations), which again is an approach explicitly included in Medicare for All bills in Congress but not in the CBO report. Such regulated capital financing, in turn, could help regulate cost growth in the longer term by avoiding investments in duplicative but profitable high-tech facilities that encourage the delivery of low- or no-value care.

Hence, the CBO’s decision to model a system that used fee-for-service payments for hospitals and other institutional providers rather than global budgets with separate capital financing leads it to underestimate single-payer savings in the short term and to ignore potential longer-term savings and improvements in the distribution of hospital infrastructure. That caveat aside, an important takeaway from the CBO’s analysis is that, overall, providers would see stable or even increased funding for patient care under single payer, even while overall health spending fell.

Provider Congestion?

While the CBO report foresees greatly improved financial access to care under single payer, it raises the specter of “provider congestion,” that is, greater difficulty making appointments or rising waiting times under single payer. Because such reform would newly cover the uninsured and improve coverage for most other people, the CBO projects large increases in the demand for care, and hence use. However, it projects that not all of the demand could be met because of supply constraints, for example, the finite number of doctors, nurses, and hospital beds. Consequently, the report predicts increased “provider congestion” that would cause some foregone care.

This prediction, however, is out of touch with clinical reality, an issue we recently explored in Health Affairs. The CBO’s approach to supply constraints is only half right. There is little question that, as the CBO assumes, a finite supply of health care providers constrain utilization increases after coverage expansions: As we have demonstrated, in nation after nation, universal coverage expansions have led to modest, or even no, societywide increases in use. Increased use by the newly covered has usually been partially or fully offset by small reductions in use among the well-covered or well-off.

Yet, these small reductions appear to be mostly due to the reduced provision of low-value care. Two econometric studies found that offsets after coverage expansion reflect reductions in the amount of wasteful care provided to the already insured. Similarly, studies by the Dartmouth Group indicate that the volume of elective and low-value care increases when the supply of doctors and hospital beds rise—a phenomenon called supplier-induced demand. In other words, faced with an increase in demand for care, providers prioritize their time and services, delivering more high-value care while reducing the provision of low- or no-value services.

Characterizing such offsets as “unmet demand” or “congestion” is hence misleading. It mirrors previous forecasts of “patient pileups” when Medicare was first implemented—forecasts that proved incorrect. In the US today, nearly one-third of all health care delivered is unnecessary or wasteful. Overprovision is common. If coverage expansion leads to some attenuation in supplier-induced demand, all the better.

A Notable Omission

Finally, while the CBO projects reductions in health spending in four out of five single-payer scenarios, as noted, it projects substantial increases in federal spending that would replace all private insurance premiums and nearly all out-of-pocket health care costs. Yet, there are also substantial savings for state and local governments with single-payer reform. The CBO’s brief mention of the savings likely to accrue to these governments (and their taxpayers) omits probable savings from no longer having to bear the costs of public employees’ health insurance (projected to total $318 billion in 2030), as well as about $162 billion in savings on other health programs. These, together with savings on Medicaid (which the CBO does remark on), would bring state and local governments’ total savings from single payer to about $800 billion in 2030 alone, reductions that provide important context for the CBO’s estimates of increased federal government expenditures.

The Economics Of Single-Payer Financing: CBO’s Bottom Line

Overall, the CBO report provides one of the most detailed explorations to date of the economics of single-payer financing. As we have noted, it makes many sound assumptions, particularly about payer- and provider-side administrative savings. At the same time, it adopts some unfavorable assumptions about the structure of single-payer reform (including some that conflict with key provisions of the Medicare for All bills in Congress), projects excessive windfalls for some providers, and asserts clinically nescient portrayals of “unmet demand.” Nonetheless, the bottom line of the CBO analysis—that universal coverage can be affordably achieved even as benefits are expanded and cost sharing all but eliminated—should reinvigorate debate over such reform.

Drs. Gaffney, Himmelstein, and Woolhandler have served as leaders of Physicians for a National Health Program, a nonprofit organization that supports single-payer health care reform.

https://www.healthaffairs.org…

February 15, 2021

James McGee, recently retired from the Transit Employees’ Health & Welfare Fund, discusses the lofty goals of single-payer reform, and the challenge posed by lesser reforms. “You’re changing the fundamental assumption from health care as a private good to health care as a public good. That is a tricky course to navigate incrementally.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

By Adam Gaffney, M.D., M.P.H.
Salon, February 11, 2021

Over the past year, COVID-19 has inundated the ICU where I work. Death and suffering have become the everyday norm. But I’ve also seen how our broken health care system amplifies the catastrophes caused by the virus.

Last spring, one of my many gravely ill patients who required intubation, and who had to be put in a drug-induced coma while the ventilator breathed for her, turned the corner after many weeks. After the breathing tube was removed, her first words expressed panic – not about the constant din of alarms from cardiac and respiratory monitors or the critical illness that she had narrowly survived — but for fear of ruinous medical bills.

She’s not alone. One in 10 respondents to a Gallup survey in April said they’d avoid treatment if they thought they had COVID-19 because they feared the medical costs. Even before the pandemic, 30 million people were uninsured, 1 in 3 Americans struggled to pay medical bills, and illness and medical bills contributed to more than half a million personal bankruptcies annually.

As our nation recovers from the horrifying second peak of COVID-19, and as it grapples with the most severe economic downturn since the Great Depression, it’s time to eliminate the scourge of inadequate health coverage – forever. It’s time to adopt Medicare for All.

Today, in the medical journal The Lancet, I joined colleagues in providing the first comprehensive assessment of the Trump administration’s impact on health, including in health care financing. We also make recommendations for action.

As we document, health protections dwindled under President Donald Trump. Cuts to the Affordable Care Act’s navigator and outreach programs, the growing red tape in Medicaid, and the administration’s xenophobic “public charge” rule that frightened immigrants away from enrollment in nutrition and health programs caused the number of uninsured to swell by 2.3 million, including 700,000 children – and that’s before the virus struck.

When the pandemic hit, Congress moved to cover the costs of COVID-19 testing, treatment and vaccination for those without coverage. Yet some uninsured patients with COVID-19 have still received large bills. And many – including those with coverage – continue to face financial disaster from deductibles and copayments for non-COVID-19 illness.

Meanwhile, gaps in coverage are growing. Millions of Americans have lost their jobs, and with it, their private health coverage. Many more have suffered income losses that will make copays and deductibles even more onerous.

Make no mistake: Study after study has found that lack of health coverage is often fatal. Each year, tens of thousands of Americans die because they’re uninsured and don’t get vital care.

But it’s not just the uninsured who suffer; cost barriers of any kind are medically hazardous. Deductibles cause women with breast cancer to delay starting chemotherapy by 6 months or more. Insured heart attack victims who fear the costs delay going to the ER – a potentially fatal mistake. For heart attack survivors, copays and deductibles for medications increase the risk of future heart problems. High insulin prices kill young people unable to afford that life-saving medication. And many patients with asthma and emphysema suffer unnecessary exacerbations and hospitalization because they can’t afford routine medications and care.

As we show in our wide-ranging Lancet report, most deficiencies in our health care system predated Trump.  His actions made those deficiencies more acute, however.

It’s therefore not enough to undo Trump’s legacy. We need to go further.

Urgent action to cover health care costs – including copayments and deductibles – for everyone is essential. Legislation introduced last year by Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.), the Health Care Emergency Guarantee Act, would cover medical costs for the uninsured, as well as copays and deductibles for those with insurance, for the duration of the pandemic.

But a permanent solution – a Medicare for All reform – is needed in the pandemic’s wake.

Medicare for All would provide all Americans with comprehensive first-dollar coverage. It would improve health and save lives, even as it would save money. A recent analysis from the Congressional Budget Office estimated that such reform could reduce overall health spending by at least $42 billion each year; the $400 billion in annual savings from cutting out private insurer’s waste would more than pay for the costs of expanding and improving coverage.

The COVID-19 pandemic will, fortunately, end. But the ongoing suffering caused by our broken health care financing system will not – unless we take action. Nobody should ever awaken fearing medical bills, much less from a coma. The prescription is clear: Medicare for All.

Dr. Adam Gaffney is the immediate past president of Physicians for a National Health Program. He blogs at theprogressivephysician.org and is on Twitter at @awgaffney.

https://www.salon.com…

By Amanda Holpuch
The Guardian, February 11, 2021

The US could have averted 40% of the deaths from Covid-19, had the country’s death rates corresponded with the rates in other high-income G7 countries, according to a Lancet commission tasked with assessing Donald Trump’s health policy record.

Almost 470,000 Americans have died from the coronavirus so far, with the number widely expected to go above half a million in the next few weeks. At the same time some 27 million people in the US have been infected. Both figures are by far the highest in the world.

In seeking to respond to the pandemic, Trump has been widely condemned for not taking the pandemic seriously enough soon enough, spreading conspiracy theories, not encouraging mask wearing and undermining scientists and others seeking to combat the virus’s spread.

Dr Mary T Bassett, a commission member and director of Harvard University’s FXB Center for Health and Human Rights, told the Guardian: “The US has fared so badly with this pandemic, but the bungling can’t be attributed only to Mr Trump, it also has to do with these societal failures … That’s not going to be solved by a vaccine.”

In a wide-ranging assessment published on Thursday, the commission said Trump “brought misfortune to the USA and the planet” during his four years in office. The stinging critique not only blamed Trump, but also tied his actions to the historical conditions which made his presidency possible.

“He was sort of a crowning achievement of a certain period but he’s not the only architect,” said Bassett, “And so we decided it’s important to put him in context, not to minimize how destructive his policy agenda has been and his personal fanning the flames of white supremacy, but to put it in context.”

The commission condemned Trump’s response to Covid, but emphasized that the country entered the pandemic with a degraded public health infrastructure. Between 2002 and 2019, US public health spending fell from 3.21% to 2.45% – approximately half the share of spending in Canada and the UK.

To determine how many deaths from Covid the US could have avoided, the commission weighted the average death rate in the other G7 countries – Canada, France, Germany, Italy, Japan and the UK – and compared it with the US death rate.

In another comparison, the commission found if US life expectancy was equivalent to the average in the other G7 countries, 461,000 fewer Americans would have died in 2018.

The Lancet commission on public policy and health in the Trump era, launched in April 2017 to catalogue Trump health policies, examines the driving forces of his 2016 election win and offers policy recommendations. The 33 commissioners are from the US, UK and Canada and work in public health, law schools, medicine, unions, indigenous communities and other groups.

The commission devotes as much time in the report to its namesake as it does to the conditions that made him possible.

A line is drawn from neoliberal policies pushed in the past 40 years, such as those that intensified the drug war and resulted in mass incarceration, to health inequities Trump exacerbated while in office. Many of the connections date back even further, to the colonization of the Americas and the persistence of white supremacy in society.

“I really think one of the accomplishments of the report is its historical truth-telling,” said Bassett, New York City’s health commissioner from 2014 to 2018.

Trump’s response to documented health inequities and growing inequality was to attack programs and policies intended to make health insurance more affordable and accessible. In Trump’s first three years in office, there were 2.3 million more people without health insurance.

Between 2017 and 2018, the health insurance coverage rate decreased by 1.6 percentage points for Latinos – roughly 1.5 million people – and by 2.8 percentage points for Native American and Alaska Native people, while remaining stable for the white population, according to the commission.

The report not only assesses health policy, but also includes lengthy sections on immigration, Puerto Rico, reproductive rights, racism and the environment. Dr Adam Gaffney, a commission member and Harvard Medical School assistant professor, said: “To only focus on medical care would neglect the many other inequities and injustices that produce health and sickness.”

The commission said evidence is growing that Trump’s regulatory rollbacks have increased death and disease. Between 2016 and 2019, the annual number of deaths from environmental and occupational factors increased by more than 22,000 after years of steady decline.

The negative consequences of the rescinded regulations disproportionately affected the states which most supported Trump in 2016. These are also states most affected by rollbacks in health insurance coverage, according to the report.

The commission did identify a positive in Trump’s domestic agenda: his support for the First Step Act, a prison and sentencing reform bill that reduced mandatory minimum sentences for a number of drug-related crimes among other things.

The commission also noted that historical advances usually follow a period of conflict and struggle and included recommendations for healthcare workers to advance progress in the wake of Trump’s presidency.

The report includes a list of policy recommendations to address the issues it raised, including providing compensation for descendants of enslaved Africans and indigenous people, raising taxes on the wealthy, reducing defense spending and adopting a single-payer, national healthcare system.

Gaffney said: “I hope this report pushes those with power to pursue the necessary policies to make this a healthier and happier nation.”

https://www.theguardian.com…

By Ken Alltucker
USA TODAY, February 11, 2021

About 40% of the nation’s coronavirus deaths could have been prevented if the United States’ average death rate matched other industrialized nations, a new Lancet Commission report has found.

While the Lancet Commission on Public Policy and Health in the Trump Era faulted former President Donald Trump’s “inept and insufficient” response to COVID-19, its report said roots of the nation’s poor health outcomes are much deeper.

Commission co-chairs Dr. Steffie Woolhandler and Dr. David Himmelstein, professors at the City University of New York’s Hunter College and longtime advocates for a single-payer health system such as “Medicare for All,” said the report, published Thursday, underscores decades of health, economic and social policies that have accelerated the nation’s disparities.

The report found U.S. life expectancy began trailing other industrialized nations four decades ago. In 2018, two years before the pandemic, the report said 461,000 fewer Americans would have died if U.S. mortality rates matched other Group of Seven nations: Canada, France, Germany, Italy, Japan and the United Kingdom.

“The overriding thing that we need to do in our country is to decrease the huge and widening inequalities that have emerged in our nation,” Himmelstein said.

COVID-19 has disproportionately affected people of color, with the death rates among Blacks increasing 50% compared with whites. Coronavirus deaths for people of color are 1.2 to 3.6 times higher than for whites; the disparities were especially high among middle-aged adults, possibly a sign of crowded living conditions and jobs that did not allow people to safely distance, the report said.

Public health measures such as mask wearing and physical distancing could have saved lives, Woolhandler said, but Trump failed to create a national response, instead leaving crucial decisions to states.

His actions “caused a lot of citizens to fail to take it seriously and interfered with the kind of coordinated response they have been able to use in a lot of countries that are more successful than the U.S. in controlling the epidemic,” Woolhandler said.

In addition to response to the pandemic, the report said Trump weakened the Affordable Care Act, and 2.3 million more Americans became uninsured, a figure that does not include those who lost employer-provided coverage during the pandemic.

The commission took aim at Republicans and Democrats alike. The election of Ronald Reagan in 1980 marked the end of the New Deal and civil rights era in favor of “neoliberal policies” that eroded social programs, the report said. The report assailed Democrat Bill Clinton’s support for tightening welfare eligibility and signing a federal crime bill that led to “mass incarceration,” disproportionately harming Latinos and Black men.

Private insurers’ charged “exorbitant overhead and profits” when extending government-subsidized coverage to lower- and middle-income Americans under former President Barack Obama’s signature health care law, the report said.

The commission suggested a long list of executive orders and legislative actions to reverse trends negatively affecting the health of Americans. Among the fixes: Adopt a single-payer health system such as Medicare for All, championed by Sen. Bernie Sanders during his run for the Democratic Party’s presidential nomination.

“We’re still in a very deep hole. We have 30 million uninsured people. We have tens of millions of more who are underinsured,” Woolhandler said. “The thing that would be best for the health of the population would be Medicare for All.”

The commission’s wish list goes beyond medical care to include progressives ideals such as the Green New Deal, criminal justice reform, repealing Trump’s 2017 tax cuts and increasing spending on social programs to the levels of six other industrialized nations.

Woolhandler and Himmelstein are co-founders of Physicians for a National Health Program, which advocates for a single-payer health system.

Biden has rejected Medicare for All and instead wants to bolster the Affordable Care Act with more lucrative subsidies for low- and middle-income earners. House Democrats unveiled a bill this week that would boost tax-credit subsidies for Americans who purchase marketplace plans. Biden already signed an executive order to reopen enrollment on HealthCare.gov from Feb. 15 through May 15.

In 2019, the Urban Institute estimated that adopting a single-payer system such as Medicare for All would increase federal spending by $34 trillion over 10 years. The think tank has not updated the study, but Urban Institute Health Policy Center fellow and economist Linda Blumberg said health care spending increases each year.

Such an ambitious overhaul also would likely need to be gradual to minimize disruption to hospitals, doctors and patients. “If you were going to do it responsibly and you were going to phase it in over a period of time, that actually makes it cost more money,” Blumberg said.

The commission said a single-payer system would save $626 billion each year on medical billing and administrative costs. While the report did not say how much Medicare for All would cost, it cited a study that found 20 of 22 models predicted total health spending would be less under a single-payer system.

In December, the Congressional Budget Office reported that a single-payer plan would increase federal spending from $1.5 to $3 trillion in 2030 over projected levels. However, total public and private health-care spending could range from savings of $700 billion to an increase cost of $300 billion. The more optimistic scenario counts on administrative savings and health providers agreeing to lower payments.

“A Medicare for All program would substantially increase economic equality,” Himmelstein said. “Poor people spend a much larger share of their incomes for their health care even though they get much less for their health care.”

https://www.usatoday.com…