Democratic Debates

Is “Medicare For All (Who Want it)” Enough?

By MIKE MAGEE

In the 2nd night of the Democratic Primary debate on June 27, 2019, Pete Buttigieg was asked whether he supported Medicare-For-All. He responded, “I support Medicare for all who want it.” 

In doing so, he side-stepped the controversial debate over shifts of power from states to the federal government, and trusted that logic would eventually prevail over a collusive Medical-Industrial Complex with an iron lock grip on a system that deals everyone imaginable in on the sickness profitability curve – except the patient.

On July 30, 1965, President Lyndon B. Johnson signed into law “Medicare,” a national insurance plan for all Americans over 65. He did so in front of former President Truman, who 20 years earlier had proposed a national health plan for all Americans, and for his trouble was labeled by the AMA as the future father of “socialized medicine.”

For Truman, there was a double irony that day in 1965. First of all, the signing was occurring at around the same time as our neighbor to the north was signing their own national health plan, also called “Medicare”, but their’s covered all Canadian citizens, not just the elderly.

The second incongruity was that Truman was fully aware that in 1945, as he was being tarred and feathered as unpatriotic by taxpayers for having the gall to suggest that health care was a human right, those very same citizens were unknowingly funding the creation of national health plans as democracy stabilizers in our two primary vanquished enemies – Germany and Japan – as part of the US taxpayer funded Marshall Plan.

Fast-forward more than a half-century, and we’re still trying to correct the error, and make Medicare available to all citizens. For nearly all Democrats, and for some Republicans, the focus now is on “for all”. The battle is centered on how we get there.

Our Medicare continues to have very high satisfaction scores among citizens over 65. So theoretically, it shouldn’t have to be forced on anyone, suggesting that pull vs. push is the way to go.

Medicare-For-All (who want it) would allow anyone who chooses to buy into Medicare. You like your employer insurance, with diminishing benefits and ever increasing deductibles and co-pays? Terrific, keep it! But if you would prefer the public plan with maternity benefits and mental health, with prevention and safeguards for pre-existing conditions, join the team. 

However, such an offering, left unaccompanied by ancillary actions, stands little chance of avoiding the same fate of the ACA with endless chipping away at benefits by self-interested detractors. 

First and foremost, everyone in America must be insured period, and the profiteering at patient expense has to stop. 

Here are three principles to guide our next steps. 

1. Less is more. Insurance Simplicity = Savings and Improved Quality and Performance. 16 health workers for every physician with half of these having no clinical function – that’s ridiculous. 

2. Health = Full Human Potential (not the elimination of disease). Innovative research is great, but it is no substitute for national health planning and public health programming.

3. The Public Option must reinsert appropriate checks and balances. The integrated career ladder that currently entangles academic medicine, pharma, insurers, hospitals and government regulators is a cesspool of conflicts of interest and no longer deserves safe haven.

In addition to eliminating insurance gaming of the system, reference pricing pharmaceuticals and outlawing DTC advertising are long overdue, and addressing physicians prescribing behaviors that can only generously be labeled “sloppy” should receive our focused attention.

Consider these latest figures on Adverse Drug Events (ADE):

● 5 million older adults sought medical attention for ADEs in 2018.

● 42% of older adults take 5 or more prescription medications.

● There was a 300% increase in polypharmacy over 20 years.

● 750 hospitalizations every day are due to ADEs in older adults.

● $62 billion in unnecessary hospitalizations over 10 years.

● 150,000 premature deaths in next 10 years due to ADEs.

Finally, there are the hospitals, whose lobbyists are already misinforming the public that Medicare rates will drive them into bankruptcy. That claim has been actively debunked. These are organizations that are interventional expansionary to their core, are chronically cobbled by preventable infections and preventable deaths, reward executive teams with automatic raises and rich benefit packages, and maintain a voluntary credentialing process, the JCAHO, that regularly green lights organizations which deserve a flashing red, or at the very least a cautionary yellow.

While we lack quality and efficiency in health care in America, we don’t lack money or talent. We have already sidelined 1 in every five dollars, and have an array of talented doctors, nurses, pharmacists and public health professionals. What we have avoided until now is the discipline and solidarity to create an actual national health plan that will utilize these precious resources to best avail.

Buttigieg is right in suggesting that Medicare, extended to all comers, will have little difficulty competing with private plans and their purposeful complexity. But to achieve the desired outcome of high quality, low variability and efficiency, our nation today requires the same deliberate trust-busting actions utilized by national leaders over a century ago to bring the robber barons to heel. Medicare-for-all (who want it) is certainly a useful carrot, but will have limited corrective effect unless accompanied by appropriate regulatory sticks.

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

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  1. Both the public sector (Medicare and the VA, National Health Services in the UK, Canada, Israel, Australia, etc.) and the private sector (Blue Cross/Blue Shield, Kaiser Permanente, Intermountain Health Care, Aetna, Cigna, Humana, etc.) have failed my personal test over the past quarter century. In 1994, I discovered how to prevent dialysis. Nobody in healthcare has wanted to eliminate it; dialysis is simply too lucrative. No matter that it’s hell for patients, and is tantamount to medical slavery: patients of color are affected 3 to 5 times more than whites. References are in: https://www.bmj.com/content/363/bmj.k4303/rr

    So how do you improve a system that cynically exploits the people who pay for it? I have a few suggestions:

    1. Avoid monopoly situations. They’re much less consumer-friendly than choice. Customers need to be able to “vote with their feet.” Forget Medicare-for-All. Keep private insurance around and a freely accessible public sector for the sake of competition. Order the public sector to solve diseases. The private sector will have to follow suit or risk losing its customers. That is, once outcomes are reported, which still isn’t being done. The private sector will have to cut costs to compete with the free public sector.

    2. The VA already has the expertise to do this. It just lacks the budget and the direction. Academics are instead incented to waste time in make-work: to become expert in a narrow subject of no practical significance. Academics have aided and abetted the status quo, anti-innovational healthcare system we’ve had for the past half-century. The Secretary of HHS’s responsibility should be to accomplish the quadruple aim of better outcomes at lower costs while improving patient and physician satisfaction.

    3. America’s 700,000 practicing physicians need to be consulted for their expertise. We need to turn our healthcare system into a learning machine, not a factory floor of interchangeable physicians all doing the same thing. Some physicians have made clever clinical breakthroughs, as I discovered after lecturing in Lubbock, TX to family physicians on how to avoid diabetic kidney failure. One of the audience members gently asked me how to delay the onset of diabetes. After 15 minutes, I finally admitted that I didn’t know how to, whereupon he shared a brilliant method of his own. How many more of our practicing physicians are going to their graves with pearls of wisdom like this? It would be so easy to capture these superior outcomes once we start recording them. We could then ask the physicians with the best outcomes to educate the rest of us. This could go a long way to preventing burnout.

    4. The PHS loaned the VA 57 hospitals in 1921. It’s time to pay back the loan, with appropriate interest. Of course everything has been paid for by the taxpayers. Give the VA back to the PHS now that the country is in desperate need of a public sector to care for our 50 million underinsured Americans. The thousand veterans I spoke to said they wouldn’t mind. Other countries have done this, such as Taiwan. The PHS was set up by Congress in 1789. It would be historically consistent for it to care for all Americans who chose to walk through its doors.

    5. VA physicians don’t work very hard. As academics, they have plenty of time for research and teaching. They see only 200 patients on average, only 10-20% of the load of physicians in private practice. (They get paid about half). So the VA/reconstituted PHS could care for five times more than its current 9 million patients without an increase in personnel or budget, i.e. 45M Americans, at no extra cost. Problem solved. Mike drop.

  2. Medicare polls well mainly because beneficiaries pay only a small percentage of the total cost. Medicare Part A is free to beneficiaries while Part B premiums are set to cover only 25% of Part B costs. By contrast, employees pay about 25% of costs for employer coverage on average and most understand that the portion nominally covered by the employer is part of compensation that would have been paid as higher wages if the health insurance benefit didn’t exist. Those who purchase health insurance in the individual market, of course, must pay the entire premium out of pocket.

    It’s also worth noting that Canada has long wait times for care that is not immediately life threatening. Americans probably wouldn’t stand for that. Canadian Medicare also does not prescription drugs. Canadians must buy a separate private plan to cover drugs.

    Moreover, health care workers in the U.S. from doctors, nurses and pharmacists to IT specialists, administrators and executives make significantly more money than their counterparts in other countries. In many cases, compensation is twice as high in the U.S.

    There are cultural issues that drive up healthcare costs in the U.S. as well. First is the litigiousness of our society as compared to other countries. So, when the medical specialty societies develop the practice patterns that define the standard of care, they are more testing intensive than in other countries to try to protect doctors from malpractice suits. Hence, lots of defensive medicine is delivered and paid for.

    There is also much more end of life care that is marginally useful at best, futile at worst and costly for sure in the U.S. People in the more socialist countries of Canada, Western Europe and Australia have a culture of not imposing unreasonable costs and expectations on their fellow citizens. In the U.S., the prevailing mentality is I want what I want when I want it and I expect someone else to pay for it.

    Finally, we like choices in America. We don’t want to be stuck with a one size fits all government plan. What if it turns out to be much more expensive that the liberal geniuses expected? With the private insurance industry put out of business by a Medicare for All plan, we would be stuck with it. Even if offering choices costs a bit more and is someone more complex administratively, it’s worth it to most of us to be able to take our business elsewhere if we’re not satisfied with the plan we currently have.

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