All for One, One For All


Within the ever-widening array of Democratic contenders for the Presidency, the “Medicare-for-all” debate continues to simmer. It was only six weeks ago that Kamala Harris’s vocal support drew fire from not one, but two billionaire political rivals. Michael Bloomberg, looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… [that] would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”

Remarkably, neither man made the connection between large-scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination. Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability.

Schultz was similarly short sighted. While acknowledging that the manmade opioid epidemic, mental health crises, and income inequality are “systemic problems” and at levels “the likes of which we have not had in a long time”, he failed to connect the cause (a remarkable dysfunctional and inequitable health care system) with these effects.

As I outline in “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/ June 4, 2019), today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature.  To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.

“Universal health care” is an end point goal that reinforces the principle that health is a human right rather than a privilege for the most entitled. It is an expression of national solidarity and reflects a shift in our culture.

“Single payer” is one strategy or tactic often associated with the Canadian health care system. However, the Canadian system is not technically a “single payer” system, in that provision of insurance (set to national standards) and the delivery of the care are the responsibilities of individual provinces, not the national government. A more accurate label for their system would be “Single Oversight/Multi Plan”.

Canada has choice and also maintains an active private health insurance market that provides supplemental health care plans purchased by 70% of citizens to cover roughly 30% of health costs including optical, dental and drugs which are not covered by government plans. Private insurers in the U.S. in the future might play a similar role.

The Canadian government’s role is focused on formalized government health planning as well as insurance standards and oversight. It also outlaws DTC drug advertising and sets prices annually for all essential drugs. The national government is the guardian of universality and (often overlooked) simplicity. Providers provide. Provincial government pays. Patients concentrate on health and wellness, and are not plagued by insurance gamesmanship and endless bill bickering on the local level.

The U.S. has no such government-directed, national health planning apparatus. Service levels and reimbursement vary widely across an endless array of private and public offerings that have devolved into a “free-for-all.” Our profit-driven, scientific research community regularly diverts resources from health planning and patient care, and our insurance system harbors an enormous number of health system middlemen to support “non-real” work (16 positions for every one physician – half with no clinical role).

What we do have are $4 trillion already committed (albeit badly misallocated), a remarkable array of educational institutions, a dedicated network of public health schools and practitioners, under-utilized nurses and pharmacists, and a testing ground of 50 different states.

The true impact of spiraling health care costs and their secondary effects—including stagnant wages, income inequality, a lack of job mobility, high rates of medical bankruptcy, the closure of rural hospitals, an inability to invest in infrastructure repairs, and our growing national debt – is staggering. We are the only developed nation in the world that spends more on health care than all other social services combined.

Warren Buffett, a man who knows something about sustainable growth, said recently: “The health care problem is the number-one problem of America and of American business. . . . Medical costs are the tapeworm of American economic competitiveness.”

For far too long, our leaders have focused on how to make American corporations wealthy. But let us be clear – there is another way. We could have the courage and the will to reapply our more than ample health care assets and reject the status quo. We could vote in change on a large scale.  We could elect leaders willing to honestly address a simple, long overdue question that is at the very center of Code Blue: “How do we make Americans healthy?”

Mike Magee is a Medical Historian and author of “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/June, 2019).

5 replies »

  1. William-
    You were way ahead of the game, and certainly on the mark one year ago, in looking toward the possibility of an “extraneous catastrophe.” Covid-19 is already in the process of changing scope of practice, type of employment, standards of coverage, and the future of employer based insurance. Who could have predicted? But you did!
    Best, MIke

  2. Craig-
    It’s fascinating to read this now, 1 year later. Your remarks laying out the challenges and obstacles are right on. Of course, the disruption of a pandemic to the institutions and the people who work in them, is profound. The movement of physicians from private practice to employed status (with income give-backs and enforced coverage rules for example), could markedly affect the trajectory of health care costs and the pace of transformation toward a national and universal care system – and, noe of this could have been anticipated one year ago.
    Best, Mike

  3. This article doesn’t say explicitly, but does admit implicitly that Medicare for All is unworkable and will not and cannot be done. Why? Because it is gold plated. The only way to extend Medicare to everyone is to dramatically reduce benefits which has two problems (1) the over 65 crowd will scream bloody murder that you have ruined the healthcare quality they were counting on (2) providers–doctors, nurses, hospitals would all have to get by with MUCH less $$ per patient which would be a shock to the system to say the least. The reason we have the highest cost healthcare in the world is because we have the best paid providers. The reason Obamacare did not take on the issue of cost was because Pelosi and Obama were too smart to take on the doctor and nursing lobby. Making healthcare a “right” means we have to either completely restructure every aspect of our current healthcare delivery system–starting with medical education (6 year degree including undergraduate), more nurse practitioners with more rights (on a nationwide basis-not state by state), lower compensation rates, outcome based compensation etc. Look to Japan which spends much lower than US on healthcare. Doctors make MUCH less there. Yes, there are savings from centralized administration, but not enough to get to the 10% of GDP on healthcare Japan spends. The other feasible approach is “Medicaid for All …below a certain income level. In this approach you are extending our already existing 2 tiered system, but expanding Medicaid even further to say anyone in the lower 50% of income levels who does not have private insurance. Medicaid reimburses at lower levels than Medicare and not all providers take this level of reimbursement. This was the half of Obamacare that actually worked. Medicaid was expanded and we should learn from history and work on that, not trying endlessly to regulate the private market to make up for gaps in the public market.

  4. Agreed! The likely occurrence of a recession would be the most likely cause.

    Unfortunately, I don’t think any of us would approve of what happens next. What endangers the next phase is best described by a lack of any broad consensus about the underlying causes for the following attributes of our nation’s worsening HEALTH:

    .maternal mortality,
    .childhood obesity,
    .adolescent suicide/homicide,
    .sedative use mortality,
    .chemical dependency,
    .mid-life depression/disability,
    .mass shootings and
    .worsening longevity at birth (now 4 years in a row).

  5. We have worked our way into a truly difficult cul de sac. There are now so many stakeholders, all making nice incomes, that the political will to change the system seems nearly impossible to gain. I think some of us are hoping for some extraneous catastrophic event to save the system: Medicare goes broke; some revolutionary must-have scientific achievement comes along that might deconstruct the financing mechanisms ( like a very costly cure for cancer); we have a very lethal public health emergency with influenza that requires a radical new approach to access, etc. . ..you know what I mean.

    But, anyway, if we extrapolate what we are now doing in health care toward the future, the U S seems to be heading into such a massive devotion of the GDP into the health care sector, that we will become weak and enfeebled–for sure–in some other vital sector of tge economy, eg, military. There is no question about this. One of these weakened sectors may finish us off.