MeDICARE FOR ALL: Better, Cheaper

Every day in my practice I see the consequences for people’s health, and their very lives, of having no healthcare coverage or coverage that is inadequate. This translates directly into lack of access to healthcare services – and to bad outcomes. Americans delay or avoid seeking necessary care, often with tragic results.

We have money to spend on healthcare. We give it to insurance companies, which are supposed to serve as a conduit, channeling the money to pay the doctors, hospitals, and other providers of healthcare to patients. But the business model of the private health insurance industry is such that a portion of that money is not spent on health care. Instead it is diverted to administrative costs that are substantially higher than we see for the government agency that runs Medicare and Medicaid, as well as marketing, return to investors, and lavish executive compensation.

Medicare’s administrative costs are much lower, there are no investors expecting dividends, there are no executives pulling down millions, or tens of millions, of dollars each in annual compensation, and the marketing consists chiefly of little ads telling seniors to call 1-800-MEDICARE if they have questions.

Meanwhile, patients and doctors spend hours on the phone trying to get the private health insurance companies to pay for things they are supposed to pay for and jumping through hoops to get them to do so.

As if all this isn’t reason enough to ditch the absurdly fragmented non-system we have for financing healthcare in this country, about ten percent of Americans are on the outside looking in, with no healthcare coverage at all. They don’t qualify for Medicare or Medicaid and they either are not eligible for employment-based coverage or cannot afford their share of the premium. Some are self-employed and cannot pay the eye-popping premiums one finds in the individual market.

And many who do have coverage through private health insurance struggle with copays and deductibles that are large enough to discourage them from seeking health care when they need it, because the costs will be largely or entirely out-of-pocket.

It is time to ditch the private health insurance industry.  It has had more than half a century to show that it can efficiently and effectively cover Americans whose health care is not financed through a government-run program, and it has demonstrated beyond any doubt that it is a failure.

Even for those who are satisfied with employment-based coverage, that very satisfaction – and fear that something else won’t measure up, or there will be a gap – is a barrier to changing jobs when such a move would otherwise be the right decision for career advancement. Employment-based coverage came into existence at a time when employers were looking for ways to recruit and retain workers in an economy that was abundant in job opportunities. Now it restricts career mobility and keeps people in jobs no longer satisfying because they cannot risk being without coverage in transition, with the cost of transitional (“COBRA”) coverage being exorbitant, and fear that the next company won’t cover a pre-existing condition.

We need a system that works like this: everyone is covered. When you are born, you get a Social Security number, and you are enrolled for healthcare. For those of us who have already been on the planet for a while, it is easy to sign up. If we don’t take the initiative to do it ourselves, the first time we need healthcare, we get signed up on the spot.

Copays?  Deductibles?  Nope.

Copays and deductibles have two purposes. The first is to get people to pay part of the cost of services that they already paid for when they shelled out money for premiums. In a public system financed with public dollars, that rationale goes away, because there is no insurance company using it to boost its bottom line. The second is to give people “skin in the game.” In other words, if you have to pay something, it will make you more sensible and responsible in your decisions about whether and when to seek health care.

There is no question that there is great variability among us in healthcare-seeking behavior. Some of us seek professional health care for every little thing, and others do so only when they are very concerned that they have symptoms that could be something quite serious. In my practice of emergency medicine I see people who have been in a car accident and feel fine, but they think they should come in “just to get checked out,” while others are badly hurt and had to have worried friends or family badger them for many hours to persuade them to seek medical attention.

Yet there is abundant evidence that copays and deductibles discourage people from seeking health care that is very necessary, even urgently needed, as much as they are discouraged from seeking care that is of doubtful necessity. Do we really want the 55 year old woman delaying going to the hospital for hours or days when she is having a heart attack, because the out-of-pocket cost encourages her to hope it’s just indigestion? I cannot begin to tell you how many times I have looked at an EKG and thought, “Well, no wonder the Tums didn’t help.”

Government-run Healthcare?

Medicare for All is not “government-run healthcare.” If the government is paying all the bills instead of just the ones from patients currently in Medicare, Medicaid, and other government-based healthcare plans, it doesn’t mean the hospital where I work, or the one in your neighborhood, or your doctor’s office will be taken over by the government. It just means they will be sending the bills to Medicare instead of to a slew of different companies, each of which has different rules and varying paperwork and employs an army of people to review claims and say, “No, we’re not paying for that.”

Imagine how much can be saved in costs by hospitals, doctors, and others who are dealing with one payer and one set of rules that are clearly understood by all. And imagine a world in which patients get the care they need, and it simply gets paid for without their ever having to do anything except sign a form saying they received the healthcare being billed.

You may not want “government-run healthcare.”  But you should want Medicare for All.  There is no good reason not to want it. But the private health insurance industry will fight it with everything they have, because it will replace them.

It is time to replace them – with a system that works for all of us, and does the job right.

Questions or Comments? Let Bob Know!