Medicare-for-All can happen, but maybe not how you’re expecting

What’s the largest medical bill you’ve ever received? OK, I don’t want to make you sick thinking back on it, so I’ll tell you mine: Back in 2012, I was slapped with a hospital bill for half a million dollars, which is more than most Americans pay for their house. This wasn’t some elective procedure, either — open-heart surgery very rarely is.

It’s important to note that this happened after the passage of the Affordable Care Act. Obamacare was a nice upgrade to a fundamentally flawed system. More people got health insurance, but it’s often still uber-expensive (and getting worse) and still fully unavailable to tens of millions of Americans. Medicaid is being throttled, Republicans are sabotaging protections, and big pharma is colluding with middlemen to rip-off patients and states. Even people with “good” insurance get screwed — personally, I just got a $500 bill for a ten-minute checkup.

Democrats are finally beginning to realize that continually trying to patch up a ship built to sink is futile. And after years of it being considered a far-left radical idea, single-payer healthcare — or Medicare for All — is becoming the mainstream position of national Democratic leaders.

To take a closer look at the momentum behind the single-payer campaign, I spoke with Dr. Carol Paris, the president of Physicians for a National Health Program. For years, PNHP has been at the forefront of advocating for universal healthcare; during the Trump administration, it has worked to both save Obamacare and educate Democrats and lobby nationally for a more complete overhaul of our still-broken healthcare system. She spoke some hard truths about the state of our politics and party, but they’re important ones for us to understand and accept as we push forward for truly comprehensive universal healthcare.

Note: Because it’s a 501(c)(3), PNHP cannot endorse any political candidates. So, I’ve separately made this list of candidates who support Medicare-for-All — CLICK HERE to donate to them!

Medicare for All has more support amongst Democrats than ever. Why do you think that’s happened?

It really began growing as the reality of the failure of the Affordable Care Act to control costs and insure everyone became clearer… I don’t think that moved the legislators, I think it moved their constituents to put pressure on them to endorse single-payer.

The Affordable Care Act did extend care for a lot of people, but costs still go up. Were you expecting that?

I was not optimistic. The best thing about the Affordable Care Act was the Medicaid expansion. We could have done that with so much less effort and expenditure of resources and just forgotten about the rest. The best part of it and what helped the most people was the Medicaid expansion. With the marketplace and the subsidies, there’s so many problems, because the private for-profit insurance industry is baked into it. That’s a big part of it.

The industry says it can do things more efficiently, but that hasn’t been borne out. What kind of tricks is it still able to pull, despite new regulations?

The individual mandate created a whole market for new customers. Then there was the requirement that insurers can no longer deny coverage to people who are either too sick to be profitable or too old and therefore more risky. Eliminating those but adding the mandate put the insurance industry in a precarious situation of having to figure out how to work around the guaranteed issue and community rating while still drawing in the mandated younger members.

So what they do is they make narrow coverage networks. So you can get a plan with a subsidy or plan on the marketplace that will bring down the cost of your premium, but they do it by requiring you to go on a plan that has a very narrow network. There was a study and it found that in New York, none of the marketplace plans included the number one cancer hospital in the city, Memorial Sloan Kettering.

As far as pharmaceuticals, they’ll just put the expensive pharmaceuticals into a higher tier so that they’re just shifting more and more of the cost of care to the consumer.

So how do you envision a full Medicare-for-All system working?

The only way to actually implement it in a way that will be cost-effective over time is specifically to do it as a single-payer strategy. All single-payer means is instead of multiple insurance companies providing insurance as well as Medicare and Medicaid and Tricare and all the others, everyone is in a single risk pool.

It really is only going to be feasible if it’s done on a national level. when you’ve got 325 million people and everyone working is contributing to the tax base that is paying for our healthcare. You’ve got a big enough tax base then to actually cover everyone’s needs for all medically necessary care — including dental, vision, and long-term care.

The problem people get hung up on is, “Oh my God, my taxes are gonna go up?” This is a situation where your taxes go up modestly and your net income goes up as well, and the reason is because when your taxes go up, it’s for covering the things that you’re now not paying for out of your after tax dollars, premiums, copays, deductibles, out of network costs. All of that goes away.

One thing I can never answer is what happens to all the jobs in the insurance industry?

Written into the House’s Medicare-for-All bill, HR 676, is funding to provide unemployment for a year and retraining for anyone who makes $100,000 a year or less in the insurance industry. And remember that we’re going to need some of those people to administer the Medicare for All plan. So the number of [of workers] isn’t going to go to zero.

I was actually just having dinner last night with a surgeon from Nashville who told me a great story. She’s a 67-year-old general surgeon and she was just saying she was so fed up with trying to get the care for her patients that they need. She does a lot of breast surgery and there’s a particular kind of breast cancer called BCRA 1 and 2, where if you have those genetic markers, it is a reasonable option for a woman to have prophylactic bilateral mastectomy, without having breast cancer.

Blue Cross Blue Shield denied the patient’s claim, her preauthorization to get this done. And what the doctor told me was that she finally remembered that a colleague of hers had quit the practice of medicine and was now working at Blue Cross Blue Shield doing preauthorization. So she called him up and he finally agreed that this was reasonable and authorized it. I’m telling you the story to say there are a number of doctors and nurses who are licensed clinicians in this country who have stopped practicing clinical medicine because they burned out and are now working for the insurance industry. These are people that could go right back into the delivery side of healthcare.

So if Democrats take back Congress and then the White House, how do you make the push for this, after the Affordable Care Act was what they mustered last time?

You’re talking to a person who is not easily persuaded that the Democratic Party is our friend. Remember that in 2009 we had a majority in the House and the Senate and we had a Democratic president and we couldn’t even get single-payer included in the discussion of health care reform. I’m actually of the persuasion that we need to have our grassroots organizing working on Republican members of the House and Senate, too. You get them to co-sponsor single-payer legislation. I don’t think that’s impossible. I think if the grassroots makes it toxic for any member of Congress, Democrat or Republican, for them not to get on board, then they’ll get on board because they want to hold onto their seat.

I think it’s great if people want to put their time and energy into Democratic candidates who say that they will support. But corporate Dems are still in control and I am not convinced that just getting more Democrats elected to office is going to turn the tide. I think what’s going to turn the tide is what we saw last week, with a new Reuters poll that showed 84.5% of Democrats and 51.9 percent of Republicans now support Medicare for All, and 70% overall.

That’s how we’re going to get Medicare, in my opinion, by also having moderate Republicans who are absolutely being screwed by the rising cost of healthcare. I think they’re going to get on board with this and say, “I’ve got to do this for myself and my family and stop listening to Fox News and astroturf groups like the Partnership for America’s Healthcare Future.”

So let’s say we do get Medicare-for-All. What happens when a president or Congress who hate it take office, as we’re seeing right now with the GOP sabotaging the Affordable Care Act?

I actually don’t want to pass Medicare-for-All legislation if it’s done the way the Affordable Care Act was passed, through reconciliation and no bipartisan support. If we do it that way, then they’re just turning it into a hot potato, just like the ACA is, and it’s just going to get beaten back and forth between parties and never have the opportunity to become the beloved program that Medicare became. What I really would hope is that we passed this legislation because there is such a groundswell of support among the American people that members of Congress simply get on because they don’t have any alternative.

We’re seeing more buy-in from the business community, especially small businesses that are beginning to realize that the Chamber of Commerce is not their friend and that it’s in their best interest to support Medicare-for-All, that it would be so much better for their bottom line. And look at the teacher strike in West Virginia, there was actually a picture of a teacher holding up a sign that said, “We’ll work for health insurance.” So I think we need to be just continuing to grow the movement among our own citizens who are day in and day out being beaten and beleaguered by the profiteering healthcare system.

One thought on “Medicare-for-All can happen, but maybe not how you’re expecting”

  1. And you’ve only scratched the surface of what a Single Payer system could do to first … improve health outcomes in this country and only secondarily … lower costs. All the coverage I see on this subject focuses on cost, and while that’s important if it determines what care a physician is likely to suggest and/or prevents a patient from getting any care at all … but the far larger benefit lies in the potential to increase the quality of care that’s delivered in this country – exponentially. And that takes 2 things: #1 data, and #2 putting the decision where it belongs – between a patient and his/her physician.

    I’ve worked in healthcare .. managed a physician’s office, designed practice management systems and EMRs .. and worked in drug development. Which gives me somewhat of a “systems level” perspective.

    #1: We have no means and/or methodology to collect, and analyze, a sufficient volume of outcomes data to inform treatment choices. The last time I looked at the number of different platforms/products for managing an ambulatory clinic .. there were 1200 of them, and they didn’t necessarily collect data in formats that could be easily integrated. The inpatient world is a little better .. only a couple of major players there.

    And if you run your clinic systems such that a physician is working off of a laptop … then s/he isn’t looking at the patient, really listening to the patient, and most especially … not touching the patient.

    #2: Drugs are evaluated for both safety and efficacy … one at a time. That’s how the FDA approval process works. And there are additional problems with the RCT model in which that approval is gained … which we could discuss at a later time. However, for the purposes of understanding a really important benefit to a Single Model … there are 2 key issues around pharmaceutical drugs that this model has the potential to change for the better. #1 is how pharmaceutical companies make their decisions on what kinds of drugs to bring to market. And #2 is what we really do .. or don’t … know about safety and efficacy when drugs are used in combination.

    #1: All of our pre-clinical data on pharmaceuticals are gathered on a single drug – given by itself – and evaluated for specific safety issues and efficacy based on specific surrogate end points .. which may or may not be especially relevant in the real world. And this disconnect between the data we gather during the approval process for a drug and its performance in the real world is xponentially true because pharmaceutical drugs – especially “life style” drugs … are almost never given alone. In 2010, MD Magazine wrote, ” the ambulatory elderly fill between 9-13 prescriptions a year (including new prescriptions and refills); the average elderly patient is taking more than five prescription medications; the average nursing home patient is taking seven medications.” This number has most likely grown as television ads targeting the growing elderly population tout the benefits of “new and even better” pills.

    We literally have no idea what happens when people take various combinations of drugs .. even those that are most often given in combination. But for an interesting “N of 1” look at this issue see a TED talk given by Russ Altman “What Really Happens When You Mix Medications?” The quick answer .. we haven’t a clue, and we aren’t collecting the data we need to analyze in order to find out.

    And then one more issue around pharmaceutical drugs … and yes, that’s after the need to negotiate for better prices. That’s the low hanging fruit. The more important potential benefits lie in a comprehensive reorganization of the entire model in which our healthcare system interacts with pharmaceutical drug companies.

    #1: Safety and Efficacy: As we begin to collect increasing volumes of data on how patients are really taking the drugs that physicians prescribe, combine these data with lab results on these patients, and correlate patterns of prescription with changes in critical metabolic indices .. we can provide data to physicians that will allow them to prescribe more safely, accurately, and “elegantly.” We can only begin to do this with the volumes of data that we could gather and analyze from a Single Payer system, although the English National Health System, the VA here at home, and systems in the Scandanavian countries most likely have some very useful data to share.

    #2: The optimal business model for a pharmaceutical company, and the optimal clinical outcomes for a doctor and patient sit 180 degrees apart. For a clinician, the goal is healing. S/he wants to see the lab results and the self report from their patients indicate that some “healing” is occurring, and not only does the patient “feel better,” but the lab results substantiate that self-report. Ideally, a patient would take a drug for a single round of treatment .. as s/he does with an antibiotic. And then s/he would cease “treatment” because the disease/problem was “healed.”

    That is not an ideal business model if you’re a pharmaceutical company. Pharma would prefer that its products reduce the unpleasnt symptoms of aging, disease, and/or treatment(s). And that a patient would never stop needing/wanting to take the drug in question. This creates a “customer for life” and a healthy, growing revenue steam. And while this view may sound a little cynical, Goldman Sachs just corroborated this in a rather “unformtunate from their standpoint” internal memo. The idea business model is to produce drugs that “cure nothing,” but instead just make a patient “feel a little better.”

    So a HUGE potential benefit for a Single Payer system would be to take control over the reinforcement contingencies, i.e. to be able to reward a drug that “cures” with a premium price, and to stop “rewarding” drugs that allow an underlying disease to continue to roll forward .. by imposing significant, ever increasing “price pressures.” It’s very simple .. we gain the ability to pay for optimum performance, and to pay significantly less for poor performance. And further, we have a chance to take a really good look at the correlation between the surrogate markers that we’ve chosen to represent a disease … with a broader set of data and see if we have indeed chosen the right things to measure. We have a problem in this country with “Medical Reversal” – see “Ending Medical Reversal,” Vinayak K. Prasad, MD, MPH, Adam S. Cifu, MD. It’s time to combine our best guesses on how to measure the success of our chosen therapies with volumes of real world outcomes data that will either prove, or disprove, our hypotheses. We are not looking to create good guys and bad guys here, but rather to create a neutral platform with which to refine our hypotheses and improve patient care.

    It’s time to put treatment decisions back in the hands of clinicians, armed with a growing body of the outcomes data they need to make the very best treatment decisions possible in collaboration with their patients.

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