Health Policy

Time to Reboot “Medicare-For-All”

By MIKE MAGEE

In the fog of the Covid pandemic, many are wondering what ever happened to prior vocal support for universal coverage and Medicare-for-All. Expect those issues to regain prominence in the coming months. A bit of recent history helps explain why.

The January 6th insurrection, followed by the past weeks two mass shootings, have served to remind our citizens that we must address a range of issues while continuing to confront the pandemic threat.

Modern civilized societies rely on a double-armed approach to maintain order, peace and security. The first arm is laws. But laws are of little value without even and unbiased enforcement.

The second guardrail of civility is culture. MIT professor Edgar Schein described it this way: “Culture has three layers: the artifacts of a culture — our symbols and signs; its espoused values — the things we say we believe; and, most important, its underlying assumptions — the way things really are.”

In the Senate chamber this week, and in Republican controlled state houses across the nation, Americans witnessed a colossal collision of reality and ideals in the form of new Jim Crow laws to suppress minority voting rights, and refusal to address gun violence.  In the wake of a constant stream of racial animus and mass shootings, this lethal epidemic demands a response as well.

Were these the only flashing alerts signaling danger ahead, that would be enough to cause sleepless nights. But unenforced or unevenly enforced laws, and value dissonance in America, do not occur in isolation, but are supported by an even more erosive underpinning – greed-induced economic inequality.

A 2019 pre-pandemic report in the Wall Street Journal laid out the numbers. While the vast majority of growth in assets in the prior three decades went to the top 10% in the US, debt increased by $9 trillion with ¾ of the debt issued to the bottom 90% of American families. For the top 1% during this period, median net worth grew 178% to over $11 million. For the rest of us, earnings had been flat while housing prices increased 290%, four-year college tuition soared 311%, and average per-capita health care expenditures rose 51%.

May 14, 2021 WSJ report from the Federal Reserve reinforced the uneven impact of the pandemic: “Almost 40% of households earning less than $40,000 a year experienced at least one job loss in March, versus 19% of households earning between $40,000 and $100,000 and 13% of those earning more than $100,000, the Fed said. And while 85% of those with no work disruption said they could pay the current month’s bills in full, just 64% of those who had lost a job or had their hours cut said they could cover their expenses for the month.”

The quickest, most direct pathway to address income inequality, safety and security is now through universal health coverage. Not only would this offer the opportunity to distribute wealth more equitably, but it would also offer the country the opportunity to acknowledge mistakes of the past, and work anew at aligning our actual behaviors with our stated values of compassion, understanding and partnership.

Where is the American public when it comes to a fundamental reboot of our inequitable and wasteful system focused on cure over care and profit over just about everything else?

The quick answer is, “They’ve moved left at a pretty fast clip.”  That’s the underlying message in a pre-pandemic poll from the Kaiser Family Foundation. The report stated that “Medicare-for-all starts with net favorability rating of +14 percentage points (56% who favor it, minus 42% who oppose it). This jumps to +45 percentage points when people hear the argument that this type of plan would guarantee health insurance as a right for all Americans.”

The uneven pandemic response, as well as a continued epidemic of hate-induced gun violence, have only served to reinforce the need for an equitable national health care system with a capacity to address ordinary and extraordinary public health demands. Expanding Medicare eligibility is the fastest pathway toward accomplishment that important goal.

Mike Magee, MD is a Medical Historian and Health Economist and author of “Code Blue: Inside the Medical Industrial Complex.“

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29 replies »

  1. Thanks, Bob. All good points. Of course, the issue of taxation applies to all federal services. The power to tax, as provided to Congress under Article 1, also implies choices, prioritization, and public support. It is reasonable to ask, for a sector now controlling 1/5 of our economy, what are we getting for our money. Are over 1/2 million dead from Covid acceptable? Should preventable hospital deaths of 440,000 annually at last count be tolerated? Must we enrich the richest of the rich while leaving large swaths of our citizenry uninsured or underinsured? If “No” to all of the above, is it possible to outplay the massive MIC and its army of lobbyists with incremental changes that they will “check and checkmate”, or is a substantial dramatic reboot the only realistic course? Best, Mike

  2. Thanks for a forthright article, Mike.

    One caution: the public poll approval for M4All tends to drop precipitously when new payroll and new income taxes are discussed.

    Yet unless we are run the whole Medicare program on an MMT basis, new taxes will be needed — and not just on the rich.

    Millions of Americans now get health insurance for free or next- to-free: that includes TriCare enrollees, employees of generous corporations, a minority of union members, seniors who still have retiree coverage, et al. These persons would all have to pay new income taxes and sales or VAT taxes, and they will not be pleased.

    Let’s say that M4All requires a ten per cent income tax (as it does in Israel). A person making $40,000 a year would owe $4,000, and this may well be less than he or she is paying now for insurance and deductibles. But a person making $500,000 a year would owe $50,000. This would never get through Congress — the Beltway alone is filled with Congressmen and lobbyists and federal contractors making $500,000 a year.

    What I am saying, Mike, is that we need to work on the transition!

  3. “The gap between private insurer administrative costs and public sector costs are much narrower than you suggest with fraud being a wild card.”

    How much narrower? Have # of coders on both sides of the billing wars declined? Have MIC CEO salaries narrowed? Have PhRMA lobbying budget narrowed? Have U.S. health disparities narrowed? (etc….)

  4. Himmelstein and Woodhandler are single payer zealots. I just plain disagree with their analysis. They also seem to have little to say about fraud in the Medicare and Medicaid programs which can’t be quantified as easily as administrative costs but if the government invested more in data analytics to catch suspicious bills before they’re paid, fraud would go down but administrative costs would go up somewhat.

    Administrative costs are a significant burden for primary care doctors but more and more of them, especially the younger doctors, work for mid-size and large groups for a salary and bonus. That way, they can practice medicine without having to deal with the business side of it.

    Insurers will tell you that their medical claims costs fall into three buckets. 40% is for hospital bills both inpatient and outpatient combined with emergency medicine counting as part of outpatient costs. Another 40% is for physician fees and clinical services including imaging, labs, physical therapy, etc. The other 20% is for prescription drugs.

    The gap between private insurer administrative costs and public sector costs are much narrower than you suggest with fraud being a wild card. There has been a lot of consolidation in the health insurance industry over the last 10 years and with the Affordable Care Act, there is much less variance among insurance offerings than there used to be.

  5. Barry-
    You seem to frequently fall back on “isn’t going to change”, and that is for certain if we never try. If we fail, it will not be for lack of resources, but rather lack of effort. With low hanging fruit like a 15% administrative waste component (https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0556-7) and 16 workers – have non-clinical – for every doctor in America (https://khn.org/news/health-care-in-america-an-employment-bonanza-and-a-runaway-cost-crisis/) quite a lot is possible. A national plan would allow/challenge us to reset priorities and redirect assets.
    Mike

  6. Mike,

    It’s interesting that you mentioned Japan which spends a relatively low percentage of its GDP on healthcare yet has the longest average life expectancy in the world. However, it also has a suicide rate that’s twice ours. Why? It’s probably because of their culture around honor and what they call losing face.

    Cultures are important. We have a gun culture in the U.S. which isn’t likely to change anytime soon. Over 11,000 people are murdered in the U.S. each year. There are lots of deaths from drug overdoses and suicides as well. Car accidents kill over 35,000 each year. I don’t see how any of that is going to change much no matter how our healthcare system is ultimately reformed. Moreover, how much are we supposed to spend on integrating nutrition, clean air and water, housing, security, transportation and jobs and who is going to pay for it? I think there is a lot of room for improvement on the personal responsibility front. No?

  7. Barry, the absence of national strategic health planning ( or disposal of plans as Trumpers did – http://www.healthcommentary.org/2021/02/23/10901/) is deadly, as we continue to experience with Covid. 40% of US deaths from the pandemic were and are avoidable. In my view, a national health program is built on public health (not MIC discovery profiteering) scaffolding. That plan integrates nutrition, clean air and water, housing, security, transportation, and jobs. In short, as evaluations of Marshall Plan results for Germany and Japan, everything begins with health care. (http://www.healthcommentary.org/2020/07/30/a-marshall-plan-for-america/)
    Mike

  8. Mike, I’ve heard it suggested by experts several times that the health status of our population can be attributed to the following determinants: 40% is due to personal behavior such as smoking, drinking, drug use, diet, exercise, and the like, 30% to genetic factors, 20% to environmental factors including nearby pollution, lead paint in the house plus socio-economic status and only 10% to the quality of healthcare one has access to. Whatever impact that Medicare for all or other such reforms might have on the cost of operating the healthcare system, it doesn’t seem like it would have much impact on societal health overall. Environmental and socioeconomic factors are hard to overcome without massive incremental spending on social programs and genetic factors are impossible to overcome. Personal behavior is what it is no matter how much we exhort people to change or stop unhealthy habits.

  9. Mike, I read the long article and disagree with most of it.

    I still don’t have any idea how much it costs to run a hospital in Canada vs a comparable hospital in the U.S. I don’t know what the differences in employee salaries are or how many employees there are per licensed bed adjusted for case mix or what the differences in occupancy rates are. I don’t know how much the greater fear of litigation in the U.S. impacts physician practice patterns. I don’t know how much differences in the culture of the two countries impacts spending on end of life care because of differences in patients’ and families’ attitudes toward end of life care are. Americans like choices in areas like healthcare and health insurance even if it costs a bit more. They don’t want a one size fits all government run plan.

    From what I’ve read and heard many times over many years is that the socialized healthcare systems do a good job with primary care and a pretty good job with emergency care. However, if you have a non-life threatening issue like needing a hip or knee replacement, you need imaging or you need to see a specialist, you will wait significantly longer for service than you will in the U.S.

    We hear all the time that Medicare only spends something like 2% of its outlays on administrative costs. Of course that doesn’t include what the Social Security Administration spends to process Medicare applications as the elderly age into the program. It doesn’t include what the IRS spends to collect the money that funds Medicare and it doesn’t include what the General Services Administration spends on the buildings that house Medicare’s employees. Most importantly, it doesn’t include all of the money that Medicare loses to fraud and other improper payments which the AARP estimates could be as high as 10% of total spending. In fact, the more money Medicare loses to fraud, the more efficient it looks from an administrative cost standpoint!

    United Healthcare currently has about 28 million people enrolled in its commercial, as opposed to public sector, insurance plans. 75% of those members are in self-funded employer insurance plans which United calls fee based plans as opposed to risk based plans. Large self-funded employers spend no more than 6%-8% on administrative costs which are mainly payments to insurers to process medical claims and provide a network plus some claims analytics. That’s a far cry from the 25% figure referenced in your article.

    I don’t buy the implication of differences in infant mortality and life expectancy statistics reflect differences in healthcare system quality. We have a lot more poverty in the U.S., a more diverse population than Canada, and a much higher obesity rate. The U.S. obesity rate in the 1970’s was around 15% and now it’s approaching 40%. It has nothing to do with the healthcare system and most overweight people don’t need a doctor to tell them they need to lose weight, eat less and exercise more. On the plus side, we have the second lowest smoking rate in the world after Canada thanks to higher taxes on cigarettes. Again, nothing to do with the healthcare system.

    There is room for improvement in drug pricing, especially the specialty drugs which account for only 1% of prescriptions but close to 33% of drug costs. Price negotiation won’t work, though, unless payers, whether government or private sector, refuse to cover a drug if the price is deemed too high even if if will help the patients it’s indicated for. That’s easier to say than to do in this country.

  10. I’ve never seen a good study comparing U.S. academic medical centers and community hospitals with their counterparts in Western Europe, Canada and Australia. How do the number of employees per licensed inpatient bed compare adjusted for case mix? How do employee salaries compare? How do average occupancy rates compare? If we had such a study, it would give us a lot of insight into where the cost differences are. We know prices are generally higher here but why? Is it because virtually everyone who works in healthcare makes more money than their overseas counterparts? Are practice patterns more testing intensive to treat the same disease or condition?

    As for Pedro / Peter’s reference to significantly lower healthcare costs in Germany, it may interest him to know that German employees pay a 14.5% payroll tax split between employers and employees on their salaries up to the equivalent of about $77,000 U.S. About 89% of the population makes less than that amount. The other 11% can buy private insurance if they want to which is cheaper for younger people. There is an additional 3% payroll tax to pay for long term care insurance. In addition, the Germans cover the cost of healthcare for children out of general tax revenue. It doesn’t sound all that cheap to me.

  11. A lot of “could’s” and “probably’s” there, Barry. Also, Pedro’s correct in suggesting a high degree of skepticism when it comes to hospital price games, waste, and profiteering. Ten years in senior management at academic medical center hospitals taught me they are little different from my decade at a Fortune 10 corporation in motives, politics, and business ethics.

  12. “Medicare only works as well as it does because there is still a significant commercially insured private sector that hospitals and doctors can shift costs to.”

    You’re assuming that hospital budgets and costs are the correct numbers. They’re numbers, like MSRP, that are made from a self realized wish and not a reality.

    “In 2017, health-care spending in the United States came to $10,207 per capita. Germany, on the other hand, spent $5, 848 on health care for each of its citizens.”

  13. Health insurance can be priced though estimating actuarial risk isn’t so easy. If liberals think Medicare can provide healthcare cheaper than private insurers, they should set a premium that would be paid for directly by employers and insured employees. ACA subsidies could continue in force to help lower and middle income people pay their premium. Medicare should be required to pay medical claims and other operating expenses solely from premium revenue just as private insurers must do. In other words, compete on a level playing field.

    Right now, Medicare only works as well as it does because there is still a significant commercially insured private sector that hospitals and doctors can shift costs to. If hospitals are correct when they claim they can’t make money if they had to accept Medicare rates from all comers, the consequences of eventual Medicare for all could be quite adverse. Then what do we do after we’ve destroyed to private insurance industry? We could raise Medicare’s reimbursement rates which would probably push total healthcare costs back to or even beyond where they were before in inflation-adjusted dollars.

  14. Thanks, Bill, for your thoughtful comments. I agree that now is the time to test employer and employee readiness to move over to Medicare as a public offering. My bias is, with the proper encouragement, we would see a massive shift, and a huge sigh of relief on the part of large (and especially small) employers. I expect that the financial industry, and legions of private insurance agents and benefit managers and coders would be less vocal in their enthusiasm. Best, Mike

  15. Thanks, Barry. As I wrote, I’ve been around long enough to hear your arguments many times, Barry, but have never known them to be true or verifiable. The arguments you make are now 40 years old and ring stale, likely even to yourself, as the world has changed (as we witnessed on June 6). You are correct to caution on what Americans are willing to do or not. But there’s a simply way to find out. Begin by offering Medicare as a public option to employees. The result will let us know if employers are ready to get out of the health care (they could still offer for-profit supplemental augments if they’d like), and if employees are tired of skimpy, high deductible plans from employers after a decade of cost-shifting. I’m willing to bet, you’d be surprised by the results. Best, Mike

  16. “I do know that the liberal democrats currently in power at the federal level absolutely want to soak the rich and corporations and that is exactly what they are proposing to do with or without republican support.”

    Where would you get the money to support struggling families overwhelmed by Covid? Where would you get the money for long overdue infrastructure repairs and projects? Seems deficits mean nothing to Republicans when produced from tax cuts for the suffering 1%.

    https://www.propublica.org/article/national-debt-trump

  17. Pedro,

    I don’t know what the goals of poor people are with respect to taxation. I do know that the liberal democrats currently in power at the federal level absolutely want to soak the rich and corporations and that is exactly what they are proposing to do with or without republican support. Liberal states including NY and NJ are pursuing the same policy. It’s more dangerous at the state level because rich people have options like moving and many of them already own several homes in different states.

  18. There is support for Universal Coverage and expanding Medicare is the best way to get there, but the Medicare for All Act of 2021 is not the way to get there. Here are 2 reasons:
    1. Hillary and Bill’s plan failed in large part because the 85% of Americans who had coverage feared losing their benefits more than they yearned for a new, untested government plan. I have not seen information to the contrary but would welcome it.
    2. The federal government took 4 years after enactment of the ACA to screw up the website and enrollment process that ultimately yielded 9 million enrollees. Do they really think it’s possible to move 150million privately insured to a new plan in 2 years? and Medicaid and uninsureds?
    As an alternative, the plan should build on what we’ve learned from employment-based plan sponsors, e.g.,:
    1. Give prospective enrollees a choice of plans and an incentive to enroll in the Medicare A and B plan designs. KFF.ORG reports that in 20 years, employers moved 73% of their workers to managed care, and in ten years, 31% to hated high-deductible plans. Let employers offer the medicare A+B Plans on a self-insured basis, of course with a MediGap plan to make it actuarially a bit better than what they had before and/or lower payroll contributions to premium.
    2. Follow the lead of the Medicare Part D Retiree Drug Subsidy program which gave employers a 20% subsidy to keep their retiree drug plans in place rather than send retirees to Part D. This reduced the cost for the government and employers.

    Learning from employers, were the reform to provide a subsidy to employers who offered self-insured A and B and to provide some price/fee relief, e.g. 125% of Medicare , for those employers, enrollment in what is already the largest group plan in the US would easily triple in 10 years and reach a “tipping point” toward widespread adoption.

  19. Barry, you need to step out of your mantra and look at history to see that “soak the rich” has not been the goal of low income people. What has actually occurred has been – soak the poor.

    I encourage you to read, “The Sum of Us” by Heather McGhee, for the historical facts that still use racism to divide and conquer to the benefit of the privileged. We are still paying for a slave based system and the attitudes it still encourages.

    I also suggest you read a blog by “Heather Cox Richardson” historian, which also chronicles history and how we got here. This was no accident.

    As for Europe, I’ve been to many countries there and they live quite well, even if houses are not typically huge compared to the U.S. and tax rates higher. But that does not isolate Europe from low income hunger and food banks. Life’s expensive.

    But the government here IS paying for charity through a system of tax write offs for the wealthy who get to pat themselves on the back and claim public compassion and responsibility on the backs of taxpayers.

  20. Mile,

    The accident of World War II history that gave us our employer based health insurance system for the working age population is what it is and it’s not easy to change even though we would probably not do it that way if we were starting with a clean sheet of paper. Even if most employees understand, at least to some extent, that their employer’s outlay for health insurance is part of their compensation, most would probably react badly if it were replaced by a highly visible tax like a payroll or value-added tax or significantly higher marginal tax rates on middle class incomes to finance Medicare for All. Like most social programs that poll well, people like the proposed benefits but don’t want to pay the cost. In general, most Americans simply want more from government than they’re willing to pay for. That’s unfortunate.

    More broadly, liberals who want to replicate the social safety net that exists in Western Europe and elsewhere are disingenuous to suggest that all we have to do is soak rich people and corporations and everyone else can have a free ride. The typical middle class person in most of the Western European countries pays close to 50% of gross income in combined income, payroll, value-added and property taxes to finance their social programs. They also live in tiny houses and drive tiny cars by our standards and pay the equivalent of $8-$9 per gallon for gas. They accept all that because they think it’s a reasonable tradeoff for what they get. I doubt that most Americans would be willing to strike a similar bargain because our culture is very different and our population is much more diverse.

    As for the cost of our healthcare system itself, I think you overstate the quest for profit. 85% of American hospitals are non-profit entities as are close to 40% of our health insurance companies by market share. It’s the medical specialty societies that develop the practice patterns that define the standard of care and those practice patterns incorporate the reality of our litigious society which means more testing than elsewhere. Most doctors will try their best to work with patients who say that out-of-pocket cost is an issue for them especially when it comes to prescription drugs. Lots of Americans want everything possible done for them at the end of life no matter how futile or expensive as long as someone else is paying. That attitude is much less prevalent in other countries which saves them a lot of money. Finally, I’m curious about how much you think doctors should be willing to settle for in income to adequately compensate them for their years of rigorous training. What’s reasonable for a primary care doctor? What’s reasonable for an orthopedic surgeon or neurosurgeon? How would you finance medical school training and who would pay for that? Do you think hospitals are lying when they say they can’t make money if they had to accept Medicare rates from all comers? There are lots of unanswered questions here.

  21. Thanks Pedro and Barry for engaging with me, and each other. There is a benefit to aging, and that is I’ve been around long enough to hear your arguments many times, Barry, but have never known them to be true or verifiable. The reality is that our current inequitable and inefficient approach to health services in America is an historic mistake, and after 70 years of profit-sharing collusion, benefits everyone involved, except the patient.
    (see https://groveatlantic.com/book/code-blue/)
    As for the hit on THCB, Pedro, some readers of my book, “Code Blue: Inside the Medical Industrial Complex” have pegged me as anti-innovation/technology/Pfizer and the lot/etc. The truth is I believe in American scientific innovation and am pleased that Pfizer/Moderna/J&J/and others have succeeded recently.
    That said:
    1. Their success in just in time, “silver bullets” and “silver linings” is no substitute for a real national public health care system built on strategic health planning, prevention, and thoughtful management of a society’s social health determinants including housing, nutrition, the environment, safety and security, transportation, and racial equity.
    2. Profiteering sectors (both for-profit and “not-for-profit”) are strong enough to stand on their own two feet and succeed. They do not require preferential treatment by the government in lax regulations, no-holds-barred patents, non-negotiable and opaque pricing, legal kick-backs within the conspiratorial PBM apparatus, and an integrated career ladder requiring heavily conflicted hospital CEOs and academic scientists back-scratching government Advisory Boards. If you believe in American scientific might, force them to perform on their own.
    3. “We built this city” with the help of Arthur Sackler (chapter 8) after WW II. With simple steps, we could also reclaim it, rebuild it, and improve it. And the Pfizer’s of the world…and sons and daughters of doctors like me, would do just fine.
    Best, Mike

  22. “The second is to provide doctors with safe harbor protection from lawsuits”

    Great, we’ll give them the same pass from consequences that police have. That’s your solution? Money was, is and always will be the motivation for over use of this medical system. We don’t have country docs much any more, they’re mostly affiliated with local hospitals that require more tests to make more money. Most doctors don’t even know or care about the cost of medical care.

    Somehow you want us to believe docs actually want to lower medical costs. I guess that’s why docs moved to Texas after 2013 tort “reform” because they were so eager to make medical care there more affordable.

    McCallum/El Paso revisited: https://www.healthaffairs.org/do/10.1377/hblog20101207.008200/full/

    As to “Ivy” league schools having problems attracting smart poor kids – blame the students is your explanation. It speaks to the wider disparities and attitudes of a country still making assumptions based on slave culture.

    You also prove to me why rich kids entering medical school is the reason medical costs are not getting lower, the rich kids bring with them an attitudinal mind set of their “deserved” earning power.

  23. There aren’t any states that have passed effective medical tort reform. There are two keys to effective medical tort reform in my opinion. The first is getting the resolution of medical disputes out of the hands of juries who can be easily swayed by emotion and glib trial lawyers. These cases should be decided by health courts presided over by judges with specialized knowledge and the power to hire neutral experts to sort through conflicting scientific claims. The second is to provide doctors with safe harbor protection from lawsuits if they follow evidence based guidelines where they exist or document why it was appropriate to deviate from them in specific cases.

    As for the socioeconomic status of medical school students, it’s all in the perspective. You may be interested to know that five Ivy League undergraduate schools have more students from the top 1% of the income distribution than from the bottom 60% despite trying hard to increase diversity through affirmative action and outreach to lower income high schools. Kids from higher income households will always have significant advantages including a quiet place to study, plenty of food to eat, parents who can help with homework, access to tutors, and lots of enrichment experiences among many other things.

  24. “If we want to reduce healthcare costs, we can start with tort reform. Our system is more testing intensive than in other countries because doctors are afraid of being sued for ordering what turns out after the fact to be too few tests.”

    No, it’s because our hospital controlled and driven health system looks at tests as a money maker fueled by hospital affiliated doctor groups . Show me where health costs are less in states that have passed so called “tort reform” legislation.

    Other countries are able to get students into medical school. But our profit-only-matters mindset is skewing attitudes on what a doctor should earn as well as what the investor class is entitled to of national resources.

    https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-05/oped1-1502.pdf

    “Secondly, the medical school admissions process favors applicants whose physician
    relatives and access to money afford prestigious experiences and shadowing
    opportunities. One in five medical students has a parent who is a physician [8]. The AAMC
    explains that the percentage of medical students from families in the highest quintile of
    household income has not dropped below 48 percent since 1987—half of students come
    from the richest 20 percent of the population—while the percentage of students from the
    lowest quintile has never risen above 5.5 percent.

  25. I’ll leave how to pay for Medicare for all for another discussion. I think advocates fail to appreciate what would likely happen under a Medicare for All healthcare system. First, hospitals claim they can’t make money at Medicare rates even with no uncompensated care and even if Medicaid rates were increased to Medicare levels. So, we have no idea how many hospitals would close or at least discontinue their least profitable service lines. Second, if Medicare rates for all patients significantly squeezed physician incomes, we have no idea how many older doctors would accelerate their retirement because they view the financial rewards as inadequate. Finally, if those considering applying to medical school view their long term earning power as no longer sufficient to justify the years or rigorous training required and the probable need to incur a lot of debt to finance their education, we don’t know how many of our best and brightest will decide not to go to medical school in the first place.

    If we want to reduce healthcare costs, we can start with tort reform. Our system is more testing intensive than in other countries because doctors are afraid of being sued for ordering what turns out after the fact to be too few tests. At the end of life, doctors in other countries are quicker to say I’m sorry but there is nothing more we can too besides keep you comfortable. When I mentioned this to my primary care doctor, he said the doctors in other countries don’t get sued when they do that. There is a good chance that they would get sued here. Moreover, part of the social compact in Western Europe and elsewhere is that you don’t impose unreasonable costs and expectations on your fellow citizens. In the U.S., the mentality is I want what I want when I want it and I expect someone else to pay for it. Finally, almost everyone who works in healthcare in the U.S. makes significantly more money than their counterparts in other countries. I don’t expect that to change, and frankly, I don’t want it to, especially for doctors, PA’s, NP’s and nurses.

  26. Always appreciate your comments Mike, they’re refreshing from what THCB has turned into, which is being obsequious to rich guys making money from tech apps while not solving the real problems of healthcare. THCB has become a reflection what is wrong with health care and America.

    We cannot claim a successful society until the inequality in health care, income, and food security, which has become a core feature of the “U.S. system”, is put right. Now we have voting rights to fight all over again.

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