Medicare for All: Still a great idea!

My last several posts have all had “Medicare for All” in the title. This makes one more. Maybe I am in a rut, or maybe it is simply the most important issue confronting health care in the US. Certainly there has been a lot written about it; just a review of very recent articles in the New York Times includes a wide variety. Conservative columnist David Brooks informs us that there is “no plausible route” to get to it, and we are told by Reed Abelson and Margot Sanger-Katz that there is “no precedent” for abolishing private insurance. The angst of the Democratic Party leadership in dealing with this newly-resurgent demand from its base is also discussed at length, with the Associated Press letting us know that it is a “divisive issue for Dems”. Robert Pear tells us about Nancy Pelosi’s plan to “expand health coverage” while being sure to not cover everyone. Of course, President Trump, not to be outdone (nobodyoutdoes the #Trumpenik!) has now announced his own plan, to completely gut and get rid of the Affordable Care Act and its expanded coverage. This is seen as a great gift to Pelosi, who needed something coming from way to her right, and now can “pivot hard” to fight to preserve ACA from the GOP rather than fighting with her own party’s progressives.

Of course, the Trump plan – get rid of Obamacare and then, well, don’t really have a plan after that, but it will be great – makes even a lot of Republicans nervous. Gail Collins has a particularly good time pointing this out, noting that

‘Republicans in Congress began desperately leaking the news that they had tried to talk their alleged leader out of the idea. The Democrats were almost swooning with joy. Really, Trump could not have made them happier if he’d announced that he planned to unveil a new tax cut called Help for The Greedy Rich.’

She also observes that the President has now moved from “who knew health care was so complicated?” to “I now understand health care especially very well”. Of course, he doesn’t – in fact, he understands it much less well than most policy makers, which isn’t very well at all, but he does understand how to both appeal to his base and please the wealthy folks who control the Republican Party, and indeed much of the Democratic Party.

It is frequently pointed out that many of the people who were most helped by the ACA, in particular its provisions that allow individuals to buy insurance at community rating, prevent discrimination against those with pre-existing conditions, and expanded Medicaid, are those in Trump’s base, and that eliminating the program and leaving another 20 million people without insurance might backfire. Paul Krugman’s column “The Republicans really hate health care” is accurate, and makes this point; for example, that West Virginia was promised better health care and more coal jobs. It has gotten only a few coal jobs, but 140,000 people stand to lose health care coverage if ACA is repealed. It remains to be seen if this will translate into folks voting against him and his minions, but I wouldn’t hold my breath. Although, even the Wall St. Journal has had an op-ed by Robert Pollin advocating for Medicare for All.

So what is it with the Democrats? The concerns that are expressed by many centrist, leadership Democrats about Medicare for All, or Universal Health Care of any kind seem to be in three broad areas: 1) Is it a good thing to cover everyone? 2) What will be the price Americans pay for universal health care? 3) Is this a politically feasible possibility? It is important to recognize that the fact that these questions are being asked at all, and that there is a significant portion of the Democratic congressional delegation who support Medicare for All, and that there is huge support among the American people, is YUGE. It is a testimony to how important health care is to us, to the fact that most of us are not buying the GOP line, and to the success that Sen. Sanders had and continues to have in raising the issue and continuing to focus on it.

First, is it a good thing to cover everyone? Answer: Yes. Everyone needs access to health care, and those who need it the most are often those who are left out of current, past, and future schemes for coverage – mainly poor, or near poor, people. It might be ok to leave some people out if those advocating it, advocating incrementalism, would suggest that the appropriate people to be left of were themselves and people like themselves, or the wealthiest, who can afford to pay their own way. But no, it is always the most vulnerable. And, anyway, there is great advantage to everyone being in the same system; the wealthy and powerful will ensure that the system works for them, and if everyone is in it together, it is more likely to work for everyone. The Times has a recent article about  Sen. Sanders saying “No to incrementalism”, which for some reason makes it sound like a bad thing. It is not. Certainly not if you and your family are being the ones left out by incrementalism!

Second, what will be the price? It will cost a lot to cover everyone. The numbers that even the sponsors of HR 1384, the Improved and Expanded Medicare for All bill whose primary sponsor is Rep. Pramila Jayapal of Washington, have put forward are very large. The thing is, though, the numbers that we spend NOW, by insurers and the federal and local governments (via Medicare and Medicaid and covering all their employees), and out of our own pockets in premiums, deductibles, and co-pays are far larger! And, of course, all this money buys us neither adequate health care for lots of people who are underinsured or have insurers denying claims, or good health outcomes. The US has for decades trailed the developed world in almost all measures of population health outcomes, and led only (by far) on money spent, both in total and per capita. Much of this money can be characterized as “waste” in the sense that it does not deliver health care to anyone, but is spent on high administrative overheads and profits for insurers and providers and drug manufacturers.

Third, is it politically feasible? This is an issue with lots of components. One highlighted by several articles in the media, such as the above-mentioned ‘Abolish private insurance: no precedent’ in the Times, are the jobs that will be lost in the insurance industry. And, although it doesn’t say it, in the offices of hospital providers who have armies of workers to fight with the insurance workers about payment. An expensive zero-sum game, except it is the people who pay. Sure, these are real job losses, but when has it been right to continue a bloated, non-productive industry that screws the whole country to protect jobs? I think never, but this is just a smokescreen for protecting profits. And HR 1384 actually contains funding for job retraining. The bigger issue for Democrats is money, money from big donors, as described in another NY Times article, ‘Even Liberal Democrats Can’t Quit Wealthy Donors and Their Big Checks’, although Sanders and Warren are the exceptions. In essence, “politically feasible” is always the one put forward by those who do not want big change to try to head it.

But there is great momentum from, you know, regular people, now. We have to keep it up and demand it from our legislators and candidates, and that will make it feasible.

The cost of health care: insurance companies, high-profit and low value care

We know that health care in the US is incredibly expensive. Those who read about health policy from a variety of sources (perhaps including this blog) know this in terms of data – our per capita cost is 50% more than the second highest-cost nation (Norway), twice what most comparable (rich) countries spend, and almost 3 times that of the United Kingdom. But you don’t have to be a policy wonk to know that health care is expensive; you just have to be a consumer who is trying to buy health insurance and is seeing their premiums go up – and their out-of-pocket costs (deductibles, co-pays, co-insurance) go up as well. All those other countries cover everyone, equitably, despite spending so much less money (and those that spend more, like Norway, have especially good coverage). Not so here.

“My premiums are more than $600 a month, which is more than our mortgage payment,” a cancer survivor quoted by the New York Timesin its August 14, 2016 article by Robert Pear “Health insurers use process intended to curb rate increases to justify them”, said. “I am grateful that the Affordable Care Act is here for my family, but I am disappointed by its limitations. All I want is a plan that makes our health care affordable, but it doesn’t exist.” She is likely to be disappointed, because this was not how the Affordable Care Act (ACA) was set up, and unless control of Congress changes dramatically, we probably will not see a fix. ACA passed because it guaranteed continued profit for insurance companies, and this has led to both the rate increases and out-of-pocket cost increases we have seen. Insurance companies can do this because the law allows them to ask for premium hikes when they are not making “enough” money. Essentially, ACA requires the American people (subsidized by the federal government if they are poor) to ensure private insurance companies are profitable. Because they believe that they have not been permitted to jack up rates “enough”, some companies (Humana, United, Ætna) are leaving the exchanges in many places.

While other counties make sure everyone is covered by some national health insurance (a national health service in the UK, a single-payer national health insurance system in Canada, and highly-regulated multi-payer systems in many other European countries such as France, Germany, and Switzerland), we have tried a patchwork that leaves many people out (e.g., the undocumented, poor people in the 19 states that haven’t expanded Medicaid), and encourages others to buy policies on the health insurance exchanges based solely on their cost. This is examined in a story by Reed Abelson in the Times from August 12, 2016, “Cost, not choice, is top concern of health insurance customers”. It notes that people who are healthy and young but don’t have employer-based health insurance are either buying the cheapest policies available on the exchanges or “particularly those not eligible for generous subsidies, are shunning plans altogether, finding all of the prices too high.” When they don't buy insurance, it messes with the insurance company model of offsetting costs for sick people with the premiums paid by healthy people, the reason for increasing premiums. And many other people, neither young nor healthy, are also buying the cheapest policy they can find because they can’t afford the cost (and maybe can’t understand the details); for these folks, it is not the insurance companies that pay the financial price, but themselves, when they get hospitalized or otherwise need costly care and discover that their “insurance” is inadequate (the technical term here is “crap”).

And this is just the health insurance contribution to high health care cost. Also very important is the cost of the care itself, particularly high-tech, high-cost care, provided to many Americans (at least those with good insurance coverage). This is driven, at least currently, by the fact that in most places, where insurance companies pay providers by piecework (“fee-for-service”), high-cost is also high-profit for providers, both individual physicians and the large institutional providers (hospitals and health systems) that often employ them. This blog, and a variety of exposés in many news articles including in the Times (particularly the work of Elisabeth Rosenthal) have given example after example of such incentives driving both the kind of care delivered and the cost of that care. In the worst instances, this is the result of rapacious greed that provides unnecessary care at very high cost. In many other settings, the opportunity for profit subtly (I hope) tips the scales toward providing high-cost, high-profit services rather than just as good, or almost as good, alternatives. But there are even more insidious drivers of cost; these are in the “everyday tests”, such as those done for screening, that in themselves, one by one, don’t seem to be excessive but multiplied by the number of people receiving them cost a lot (and make a lot of money for providers). The practice of ordering such tests is often driven by advocacy groups, providers in certain specialties and relatively small numbers of people with a specific condition who think everyone needs to be tested for it.

A good example is screening for lipid disorders (basically, high cholesterol) in children. Yes, some children have a genetic disorder which means that they should be tested and treated, but the vast majority do not and screening them (barring a history of familial hyperlipidemia or very early heart attacks) should not be done. It is not recommended by either the US Preventive Services Task Force or the American Academy of Family Physicians (AAFP), nor by the UK National Screening Committee. This example is discussed in an outstanding editorial in JAMA Internal Medicine by Thomas B. Newman, Alan R. Schroeder, and Mark J. Pletcher published on August 9, 2016, titled “Lipid screening in children: Low-value care”, preceded by the tagline “Less is more.” The authors contrast the USPSTF and AAFP recommendations to those of the National Heart, Lung and Blood Institute of the NIH, endorsed by the American Academy of Pediatrics, which recommends it. The authors of the editorial demonstrate the amazing lack of cost-effectiveness for this screening test, and note that is only because USPSTF does not consider cost-effectiveness that it gave the test an “I” (insufficient evidence to recommend for or against”) and not a “D” (recommend against testing).

But the most important point made in the editorial is that our recommendations for testing – and how to spend our healthcare dollars – are individually focused, and virtually ignore (and thus dramatically underfund) those interventions in public health and the social determinants of health that would truly make a major difference in the health of millions of Americans. The authors say it extremely well:

Tackling major public health concerns such as climate change, poverty, obesity, and gun violence is likely to yield high-value solutions, and many advocate policy and community-level interventions that might achieve such solutions. Meanwhile, other segments of our health care establishment continue to try to solve health problems by doubling down on individual-level health care solutions that tend to be low in value...The need for clinicians and leaders to focus on sustainability and health care value has never been greater, and it is likely that policy and community-based interventions will get us there much more quickly than adding more clinic-based interventions that have low value and are wasteful of resources and clinicians’ time.

We need to take this advice to heart. It goes way beyond lipid screening in children. It means supporting interventions that actually  improve the health of the public on a large scale. And, as always, “support” is spelled M-O-N-E-Y.