Democratic politicians are increasingly bold about supporting a Medicare-for-all or single-payer healthcare system as a means of extending coverage to the tens of millions of Americans currently lacking insurance.
But two things are quickly becoming clear as presidential wannabes, including Sens. Kamala Harris and Elizabeth Warren, jockey to establish themselves as the Savior of American Healthcare.
First, no one other than Vermont Sen. Bernie Sanders has committed to any details about how a Medicare-for-all or single-payer plan would work. And Sanders’ plan is so idealistic, it’s a non-starter.
This means voters will largely be left to guess how each candidate would pull off what he or she is promising.
Second, Medicare-for-all advocates desperately need to work on their messaging, because they’re allowing conservative opponents to frame the discussion with sky-is-falling fear tactics and outright lies.
“The Democratic plan would inevitably lead to the massive rationing of healthcare,” President Trump recently declared.
“Doctors and hospitals would be put out of business,” he said. “Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.”
Those dire predictions — and Trump’s warnings this week about socialism run amok — would be laughable if the stakes weren’t so high.
Nearly 14% of Americans lack health coverage, the highest level in five years. We pay about twice as much for treatment as people in other developed countries. Healthcare spending makes up almost 18% of total U.S. economic activity, compared with an average of 9% elsewhere.
When Democrats talk about Medicare for all, they’re not just trying to rally their political base. They’re trying to address serious problems — problems that affect all Americans.
Where they’re falling short, at least so far, is in making that case to the nation in clear, precise terms.
“Prices for medical care services and administrative costs would likely be lower than the current system,” Jean Abraham, a professor of healthcare administration at the University of Minnesota, told me.
She was quick to add, however, that “until there is an actual piece of legislation with specific benefit design provisions and offsets to pay for the legislation, it is not even possible to model what things would look like.”
Would a Medicare-for-all system mean the end of private insurance, or would it work in tandem with private insurance, as is currently the case?
Are we talking about expanding the existing system to anyone who wants to join, without any age restrictions? Or are we talking about a switch to a comprehensive single-payer approach like in Canada or Britain, in which the government pays for nearly all treatment?
Would everyone be required to take part, or would participation be optional?
Then there’s the question of cost, which has quickly proved to be the easiest thing for opponents of healthcare reform to attack. For example, the price tag for Sanders’ plan has been put at $32 trillion over the first 10 years.
This figure is deceptive, however, because it doesn’t reflect the way current healthcare spending would be incorporated into the new system. By some estimates, overall healthcare spending gradually would go down under Sanders’ approach.
I’ve been particularly struck in recent weeks by news stories correctly observing that taxes would have to go up to fund a Medicare-for-all or single-payer system.
What these stories almost always omit, though, is that higher taxes would replace the nearly $11,000 that Americans currently pay in average premiums, copays and deductibles. Many economists say people’s costs would decline under a single-payer system.
“One could make the point that taxes would go up, and premiums and copays would likely go down,” said Katherine Baicker, dean of the University of Chicago’s Harris School of Public Policy.
But she noted that “whether you're better off financially will depend on your tax bracket as well as your current insurance.”
That’s another way of saying that if you’re in the middle class or at the lower end of the economic spectrum, you’d likely find single-payer both more affordable and more reliable than your current insurance.
If you’re at the top of the economic food chain, then it’s entirely possible a single-payer approach would represent a step down from the gold-plated plan you now enjoy.
I’ve looked at the various single-payer systems worldwide. The best system for the United States, I believe, isn’t the all-inclusive British system. It’s likely closer to what they have in Germany, France and Japan.
Known in healthcare circles as the Bismarck model (after Prussian Chancellor Otto von Bismarck, who originated the idea in 1883), this approach relies on payroll deductions to fund nonprofit insurers and requires that they cover everyone.
It also sets base requirements for what must be covered and how much can be charged for treatment. The state plays an active role in maintaining an accessible and affordable healthcare market.
That said, the Bismarck model leaves plenty of room for private insurers to compete by offering more affordable coverage to younger people, or additional benefits for those willing to pay more.
I suspect this would be an easier sell for Democrats than a wholesale switch to, say, the Canadian system, which relies on the government to pay all medical bills.
Use Medicare for all as the base and then allow private insurers to supplement the program.
Just as important as clearly defining what’s being proposed, political leaders must communicate the need for patience and maturity during any healthcare transition. If Obamacare taught us anything, it’s the need to expect the unexpected. (“But he said I could keep my doctor!”)
“On average, utilization per person will go up, because all the uninsured will get coverage, and will therefore demand more care,” observed Vivian Ho, director of the Center for Health and Biosciences at Rice University’s Baker Institute for Public Policy.
“And if you get rid of the distinction between Medicare and Medicaid,” she said, “utilization goes up even more.”
Ho also warned that “many doctors and hospitals will rebel” if their reimbursement by a state-run or state-regulated insurer goes down from current levels, which it almost certainly would. “They’ll insist on a supplementary medical care system where they can charge higher prices,” she said.
Standing up to such self-serving demands, and convincing the medical establishment that today’s obscene profit margins are unconscionable, wouldn’t be easy.
Conservatives in particular would have to resist their usual knee-jerk response that “the market” can solve all our healthcare woes. If it could, we wouldn’t have had 50 million uninsured prior to Obamacare.
The political right would need to commit instead to helping find common ground that works for all, in the best interest of the nation. To date, that hasn’t been their default position.
It feels like we’re reaching some sort of inflection point — a national reckoning that our healthcare system doesn’t function as well as desired and that changes are necessary. Happily, we’re not flying blind.
We know from the examples of other developed countries what works and what doesn’t, and we have the luxury of building on the lessons they’ve learned.
My suggestion: Take politicians out of the equation and create an independent body to oversee our healthcare system, much as the Federal Reserve oversees monetary policy.
Let’s decide where we want to go and then rely on these independent, qualified experts to get us there, without all the histrionics and gamesmanship from those trying to score political points.
Like I say, this is a process that would require levels of patience and maturity that Americans do not normally display.
Agree or disagree with what’s on the table — that’s your prerogative.