Starting With Curious

As I shared in part 2, “Medicare for All” is really a slogan that encompasses several different approaches to increasing the role of government in the financing of health care, and would represent steps toward universal coverage.  Lots of people, including nearly all folks running for the 2020 Democratic presidential nomination, claim to support MFA, though they differ on which version (and some have endorsed more than one).

A few thoughts all this:

1. All versions would dramatically increase the government’s role in funding health care. The first option would likely increase the government share of health spending higher even than in Canada or the UK.  But keep in mind that government spending is already more than half of all health spending in the US.  None of the current recipients of this spending (seniors, veterans, etc.) are clamoring to do away with it, it has broad public support, and even those politicians who claim to want to move toward a more market-based system are only tinkering around the edges.  The genie of government role in health care is not going back in the bottle.

Moreover, none of these plans, even the most far-reaching, would mandate any significant change in the US provider system, which is and would remain primarily private.  Like most of the countries who have achieved universal coverage, this is not actually a socialized system like the National Health Service in the UK or the VA and Department of Defense here in the US.  Medicare for All is not the first mile on the road to becoming Venezuela.

2. The success of any of these needs to recognize that Medicare (and even more so Medicaid) currently fails to cover the cost of providing care. We have managed this for years by shifting costs to the private sector.  The less private insurance there is, the less opportunity for shifting, and the more the government will need to adjust their payment rates in any of these MFA variations.  Any calculations of the cost of any MFA plan that does not account for this and assumes we can simply extend current Medicare or Medicaid rates is underestimating the total cost by at least 10-15%.

I fear that part of the popularity of these plans is the belief that we can achieve universal coverage without any hard choices.  We underfund schools, roads, and other government services and then complain about the quality.  By and large, you get what you pay for.  There is some waste in the current system – overutilization driven by financial incentives and (to a much lesser extent) defensive medicine, high overhead due to the complexity on the payment side, excessive marketing and profit – and some fraud and abuse (though far less than many think).  But the overall cost of achieving high-quality, universal health care will be high, no matter how we go about it.

3. Every single one of these variations will have entrenched opposition. No matter how popular with the public, the battle to enact any expansion of government-sponsored coverage will make passing the Affordable Care Act look like a walk in the park.  And while the ACA did not solve all our problems, it was a good start.  My advice to those who want to improve health care is don’t let the perfect get in the way of the possible.  And don’t use Medicare for All as a purity test or weapon in partisan warfare.  The 2020 presidential candidates generally support some variation on a path to the goal of fairer, more affordable, more accessible health care.  Look at specifics, test assertions and assumptions, ask if a plan represents progress.  A journey of a thousand miles begins with one step, and the road to universal health care is a long one.  Slogans aren’t policy, and no nation’s health system fits easily on a bumper sticker.