Opinion

Medicare for All equals quality health care for none

Physicians do not pursue years of training to be told how to practice medicine by legislators and business people.

Ashley Watson, OMS II
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Editor’s note: This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA. This is a response to a recent opinion article that supported Medicare for All.

Osteopathic students and physicians agree that an arbitrary system of cutting costs and superseding clinical judgement is a terrible health care system. The debate lies in what type of system is best to avoid these problems.

Cost and wages

Future DOs, who commonly have debt burdens of over $240K, agree that protecting our physician wages is important. As others have noted, $471 billion annually is spent on billing- and insurance-related costs. Formularies are dictating and delaying treatment, and this situation has been worsening since the 1970s.

It has also been significantly contributing to physician burnout rates and threatening wages. However, Medicare for All would make documentation worse, and the decisions will then be centralized and irrefutable. The last traces of physician autonomy will have vanished.

Jared Bernstein, former economic advisor to Vice President Joe Biden, and others are convinced that Medicare is currently underfunded. Meanwhile, a new study by the Mercatus Center in Virginia estimates implementing Medicare for All would cost $32 trillion—a completely unsustainable figure.

Physicians in the backseat

The American Consumer Satisfaction Index shows that patient satisfaction with health care has been steadily decreasing. After the Affordable Care Act has made so many changes to the scope and use of Medicare, it would make sense that we need less Medicare in our system and not more.

Reports that 70% of physicians spend 10 or more hours on administration per week should come as no surprise when the burdens imposed by Medicare, to prevent fraud and misuse, are considered. Adding more requirements, with a higher patient load, to the Medicare system would overwhelm it, as it did the VA, and make health care a nightmare that more funding wouldn’t solve.

Physicians do not pursue years of training to be told how to practice medicine by legislators and business people. Patients do not seek physicians who cannot help them make informed decisions. Alfie Evans stands as a stark and tragic reminder of the consequences of promoting health care models that have neither the patient’s nor the physician’s best interests at heart.

The solution(s)

Most would agree that our current situation is not working. Cost of care, quality of care, and physician quality of life are all major considerations.

Americans and physicians need to consider diversifying how medicine is paid for. Cash-based practices and direct primary care models are routes more physicians and patients are seeking as effective solutions.

Direct primary care models are supported by several political parties and companies, including Amazon and Dell. These models and cash-based practices are appealing because they avoid the pricey markups for some procedures when patients use insurance. Cost-sharing groups like MediShare, Good Samaritan, and others are faith-based insurance alternatives that help when the cash price cannot be paid; they currently serve roughly 1 million patients.

More importantly, patients experience better care because their physicians have the freedom to treat them as they judge most appropriate, patients can autonomously select providers, and there are payment solutions available. Administrative time and personnel required are both dramatically reduced in these models, which further lowers costs and improves efficiency. The solution to fixing our health care system is already here and growing.

Call to action

Unscrupulous health insurance companies and unsustainable health policies need to be removed from the system that cannot afford them. We as an osteopathic medical community can stand and ask for better health care, more freedom, and happier patients without Medicare for All, or we can succumb to the sugar-coated ideals of a society where no one pays for anything except through ever-increasing tax rates.

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25 comments

  1. Cristian Skinner

    Mercatus institute is a deeply “free-market” think-tank, funded by, among others, the Koch brothers. Thus they are hardly a group to be trusted to give unbiased figures.
    As a society WE choose what is important to us. Is money our primary thought or are our fellow humans our focus?
    Only person who has not seen first-hand how many suffer from abandonment to the free market can believe it is the best solution for everyone. In a time of “Prosperity Doctrine” in churches and Ayn Rand quoted in Congress (and vice-versa) it is not surprising that people think that “money-first” is not only viable, but even a means to Medicine’s ethical ends.
    However, history has shown that free actors acting selfishly lead to concentrated wealth and deep poverty. Only societies which intentionally and directly seek the betterment of every human have arrived anywhere close. Should we create and maintain a broken system to provide healthcare? Despite the fact we’ve been doing that for a century, I think not. The solution is to intentionally build a system that can affordably make sure every patient can get the medicine and treatment they need. In order to do this we have to stop believing the lies of 50 years ago that everything can be solved by a 100% free market and that socialized solutions are somehow inherently evil and unworkable. Alternatively we can continue to pour money into a broken system and hope.

    Reply

    1. Michael P.

      I think I’d rather read an article by YOU on universal healthcare than by the author. As soon as I saw the biased funding of that study, I knew that it’s findings could be disregarded.

      Reply

    2. Joe W Morgan

      I am in agreement with your comment. I am 74 and semi-retired, and have seen commercial insurance continually rip off customers. Example is there are 52 BCBS companies, one for each state and two for others. The top man at each company takes home a minimum of $25 million. Multiply that by all other insurance companies and include the scam companies that sell young couples and not cover maternity, and many other scam companies.
      All that money- the profit motive in our medical system- does not go to patient care.
      Until we take the profit motive out of care, it will continue to cost way too much.
      Conversely, as we blindly accept tax cuts to those best able to pay their fair share, we dump the tax burden to the very people who struggle to pay for medical care.

      Reply

  2. Matt Harrison

    Thank you for posting Student Doctor Watson’s opinion piece in opposition to Medicare for all.

    It’s nice to hear both sides of an argument, in order to understand it completely.

    I have contemplated unsubscribing from “The DO” multiple times over the last year, due to its seemingly increasingly Liberal stance on American healthcare. You have dissuaded me from unsubscribing somewhat longer by posting this opinion piece. Thanks for staving off the inevitable a little longer!

    Medicare for all = WE’LL ALL BE BROKE, and AMERICA BANKRUPT

    Matthew Harrison, DO, MPH

    Reply

  3. Jacob Groen

    “The last traces of physician autonomy will have vanished.” This is not even worth rebutting because it’s pure rhetoric.

    $240k debt is not fun. But starting at $150k-$200k/year salary in primary care after residency is plenty to pay off that debt. Let’s not conflate the capitalistic failings of our education system with the economic hurdles our patients face in accessing healthcare.

    Direct Primary Care (DPC+) is a great model for people and companies with deep pockets. However, it is not sustainable on a large scale (DPC+ doesn’t cover OB or Surgeries, which means participants have to carry traditional insurance too or pay exorbitant out of pocket costs for L&D and surgeries). I’m a big fan of DPC+ but it’s not a magic fix. Maybe it will be a component of a grander solution.

    This article willfully turns away from the poorest of Americans and funnels them into a paradigm where we need to “diversify how medicine is paid for.” This is a callous perspective, which could cause millions of people to lose healthcare access in this proposed paradigm. Healthcare access is a right, not a privilege. We don’t need to further diversify medical reimbursement. That will make our system more complicated and less equitable.

    We need to drive healthcare costs down. We need more cost control. We need to stop holding on to capitalistic ideals in the healthcare market and find compassionate yet pragmatic solutions that works for everyone.

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    1. M.A. Mitchell, D.O.

      The last comment is truly socialist. Really? Just because it has worked SO WELL everywhere else, is that a reason to travel down the same dark rabbit hole?

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    2. Sean T.

      240k in debt, coupled with 90k/year salary for general practitioners. If the government is funding physicians salaries, that is the eventual ending, according to what everyone else is doing. I know I would not go into medicine with figures like that. Neither would any of my peers with work ethics and resumes that are comparable to the average current medical student.

      https://www.telegraph.co.uk/news/health/9300823/Most-doctors-are-not-paid-six-figure-sums-figures-show.html

      Reply

  4. Dr. “T”

    I feel frustrated reading articles like this because it makes me feel like doctors have absolutely no say in what has happened to healthcare. Doctors have not been able to stop any of the horrible changes which have occurred to healthcare and we continue to struggle with the dictums which are being shoved down our throat. Our representatives through the AOA, AMA and other physician organizations who supposedly have our “back” have not been able to stop the government’s new policies and especially CMS for making their ridiculous rules and regulations. The reality is that once the government gets involved in things, the individual gets lost in the maze. The negative changes which have occurred in healthcare are simply a nightmare. I was one of the lucky ones who at least could take care of patients years ago with respect and a wholesome approach before the government got involved in healthcare. I, like many others have retired due to my overwhelming frustrations with my last jobs. We need our representatives like the AOA to truly step up to the plate and MAKE MEDICINE GREAT AGAIN!

    Reply

    1. Michael S

      I am tired of hearing about health care as a right. Health care begins with personal responsibility for one’s own health. If you have honored that personal responsibility, then you have earned the right to health care. But if you are a fat slob who overeats and doesn’t exercise, don’t come to me for bariatric surgery!

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      1. Charlotte

        I am tired of self-righteous attitudes that that self-serving. Fine to judge poorly those in society who take take take but don’t give anything in return. But why deny their children health care. Maybe you help stop the cycle of abuse.

      2. Joe W Morgan

        My, aren’t we judgmental. In fact the education system has abandoned health as a subject so our students don’t learn health habits. If you are poor you wait until you cannot wait any longer to get care you need. If you need dental care, which is very pricy, you will have to pay or lose teeth-
        Your bias against fat people is one of the oldest and worst of our profession.
        Every physician today should address that to patients but it gets put off and back to primary care, who does not address it due to bias for too much of the time.

  6. Brian Kominsky D.O.

    As has been pointed out above, the Mercatus center is funded almost entirely by the Koch brothers. They are not interested in impartial studies and never have been. However, even if the study is to be believed, they themselves point out that Medicare For All would save about 2 billion overall per year, based on what is spent in the current system. Healthcare spending is currently 17 percent of GDP already.

    Any plan that is realistic must take into account a number of things that are not being addressed.

    1. Doctors working in the system should be reimbursed for their education expenses. Their livelihoods are being artificially reduced, so it’s the right thing to do. Trying to pay off crushing debt in a Medicare for All system would be impossible, not to mention soul crushing.

    2. Patients should be responsible for reasonable co-pays and deductibles along with the “premium” payments. And there needs to be a reasonable maximum out of pocket. Medicare is not free. It’s actually fairly expensive if you get sick, causing almost everyone to buy supplemental insurance to cover the large potential expenses. This needs to be done away with.

    3. Every patient, even those being given free healthcare (medicaid or equivalent) should have to pony up at least a couple of bucks at the time of service because over-utilization is a reality if anything is totally free.

    4. Prescription drugs need to be cost regulated. Something like only allowing drug companies to charge the median world price for their drugs. Because Americans are currently paying the freight for everyone taking medicine throughout the world. Canada’s national health service doesn’t include medication and even they pay a small fraction for medication of what Americans pay. And if drug companies complain, they can have their exclusive patent years reduced.

    5. Malpractice premiums and awards would have to be addressed. Not done away with, but set at reasonable levels.

    There are more things that will need to be addressed. In fact, I’m sure any actual healthcare bill will be about 2000 pages long if history is any guide. But there are a couple of additional points in the editorial that need to be addressed. Any practitioner will tell you that their friendly neighborhood HMO is already restricting a lot of what they can do. Usually it’s evolved from science based medicine. Sure, this reduces the “art” of medicine. But unnecessary tests and treatments, long a part of medical entertainment, are quickly going the way of the dodo bird anyway. Medicine is already highly regulated and that’s not going to change.

    And appealing to emotion with the Alfie Evans case is a little silly. The poor kid was dying and every doctor who saw him and his scans knew it. His case was more of a religious/emotional appeal than a medical one. And the correct decision was made. Of course, in the U.S., if the parents wanted to take their terminally ill child to Italy to be treated differently, all the parents will have to do is pay for it. I’m sure they’d set up a Kickstarter and be off to the Vatican in no time. But like Terry Schiavo, medicine based on wishful thinking is simply that.

    I applaud Student Doctor Watson’s spirit. But the current system is not working and nobody, not the government, and certainly not the Koch Brothers, will ever allow a truly free market to happen. And in that case, best to take care of the most people in the most reasonable way possible.

    Reply

  7. Mary Ann Block, DO

    The choice to “go along” with the system is made by each doctor individually. When I started my practice, HMO’s were just starting out. I went to a meeting where I was told how it would work. “If your patient breaks their hip, give them a walker and hope they die before they have to have surgery.” Yes, they really said that.

    I walked out and started my fee-for-service practice. I can spend as much time with a patient as they need. I can run appropriate tests and prescribe drugs I think they need based on my medical education and their history. In spite of that, I get letters from insurance companies telling me I should prescribe a cheaper drug. My patients can file with their own insurance company but it they don’t pay, the patient still got my time and the treatment we decided upon. My patients are not all rich, either. They are people who prioritize their health.

    I remember the days when everyone paid out of pocket to see a doctor and we had catastrophic insurance for hospitalization and cancer treatments. There was patient responsibility then. Patients didn’t just go to the doctor because they didn’t have to pay anything. It still surprises me when parents bring their child in for a runny nose and a low-grade fever. When did parents stop knowing how to take care of their children? I watched my parents on Medicare, go to doctors and never take out their wallets. Fortunately, they did not want to abuse the system but plenty of others do. They go to the doctor, the doctor gives them a prescription. The elderly do not need all the dugs they are prescribed.

    The system is broken. I do think everyone should have medical care and not go into bankruptcy when they are sick. Medicare for all is not the solution. There will be no new ideas, no helping people be well. There will be only more drugs prescribed and more making the drug companies richer. My patients deserve more than 7 minutes of my time and a prescription. That’s all they’ll get with Medicare for all. Medicare already limits care for those who have it. If there is no competition, they can limit everyone’s medical care even more.

    Health Savings Accounts could be the answer. We pay into the accounts while we are young and well. We have the catastrophic insurance in case we get really sick. The government pays into the accounts of those who truly cannot afford to do it themselves. Everyone, including those that the government paid for, gets a card that allows them to go to any doctor they want to see. The playing field is now even. Everyone has access to the care they want. As for us doctors, if we don’t help the patient, the patient won’t come back. It forces us to be better doctors and it allows the patient to be discriminating about how they use their dollars, since they are their dollars, not the government’s dollars. If they want to buy supplements instead of taking a drug, they can do that. It’s their money.

    The doctors don’t have to spend all their time on administrative paper work or hire two people to handle insurance. It saves time and money and gives everyone better care.

    Doctors allowed all this to happen. They could have said, “No”, I won’t participate. They didn’t. They went along with whatever the insurance companies and the government decided they should do. Now we are in this situation and it’s not good for anyone. Let’s stop just going along and be a part of the solution with new ideas. Mine is not the only good idea out there, but we need to start thinking differently and the doctors, not the government, need to be providing the answers the medical community needs.

    Reply

    1. David K.

      Did you know that the United States is one of the few countries where it is legal for pharmaceutical companies to advertise directly to patients? When considering reforms for the medical system, that’s something to think about when it comes to polypharmacy and needless prescriptions.

      Reply

  8. Michael S

    Universal health care is provided in all major countries throughout the world, at better quality and significantly less cost than in the United States. Why? Other countries are not burdened by the tremendous bureaucratic structure generated by Medicare, Medicaid, the insurance industry, and the Unaffordable Care Act. This is the big picture, a healthcare model drowning in the bureaucratic morass of rules, regulations, and documentation. And in the physician’s world, the “documentation” has become more important than the patient! And nurse practitioners, with little education and less training, are considered equivalent to physicians. The present model has failed, and it is impossible to fix. We need to take the best of what has worked in other nations and start over.
    And one more thing. Health care is a human right but also a human responsibility. Each of us is responsible for our own health first, and the right to health care will follow. But when we allow ourselves to become fat sedentary slobs, we don’t deserve the extraordinary care of bariatric surgery, etc. Too much of the health care dollar goes to people who do nothing to benefit their health.

    Reply

    1. Joe W Morgan

      See prior post on bias against obese people. Most of our population is overweight and obesity leading to diabetes, and knee replacements, and other degenerative conditions is very common.
      So why aren’t all doctors addressing diet and weight control all the time to address these problems?
      It is far easier to let them go by and after they are gone call them fat slobs.

      Reply

      1. Sean T. DO MBA

        Mr. Morgan,

        I agree, that labels, and blaming, are not useful. I would argue that we live in a society that incentivizes bad health. Medicare for all would likely propagate this incentive. The other countries with universal healthcare always referenced do not harbor populations as large as ours, a prominent military force, or a corporate presence (job market for our larger population) like the USA does. The inefficiency of their government is not as menacing when their bills are much smaller. Until we are willing, as a nation, to pay higher taxes, this simply wont work. Im not going to be DO for 90k a year (UK average for a doc). I can make way more in other fields (and if you fault me for this, I am at a loss for words, history has proven that not incentivizing hard work and sacrifice leads to the failures of post ww2 soviet union). We need to incentivize better health – the USA is richer than everyone on average, yet fatter than everyone, on average. We need to incentivize healthy lives by making the quick fixes of medicine (heart stents, etc) that should, and do, cost a lot, expensive. Not place that cost on me, as the high earning individual.

  9. David K.

    I never really understood the “I don’t want government telling me what to do” line, because it seems to imply that you’re not being told what to do by someone else.

    When I was in residency, it seemed like at least once a month I’d be receiving mail from an insurance company telling me that they were no longer covering a certain medication that one of my patients was on. “This isn’t medical advice,” they would helpfully say, before listing an alternative medication that they were now covering. Even if neither the patient nor I liked it, guess what medication they were switched to? And how many times did we need to order a certain study first, before we could order the study that we really wanted, because insurance wouldn’t pay for it if we went out of sequence?

    But your standard residency clinic patients are special, right? Now I’m in fellowship, and pretty much everyone I see not only has insurance, but they don’t have the lowest-tier insurance plans, and they’re not all living at the poverty or borderline-poverty level. What luxury, right? Yet insurance still heavily dictates our medication prescription strategies. It’s no longer quite as severe as it was during residency, but we’re not free to do everything that we want. We’re still answering to the insurance companies.

    If I have to answer to someone on my patient’s behalf, I’d rather answer to an entity that was at least designed for the public good, rather than one that was designed to earn a profit.

    The estimated cost (key word being “estimated”) may be unsustainable, but then the status quo isn’t sustainable, either. I’ve lived in five major cities at this point, and while each of them had their own medical culture and lay of the land, they all shared one thing in common: hospitals were merging and/or closing. It’s unpleasant in cities, but has the potential to be catastrophic in rural areas, where access is already an issue. Word amongst the more senior doctors was that inpatient care is growing unsustainable, and many hospitals will convert to ambulatory centers to try and remain in existence. It’s better than losing all services, I suppose, but it’s still a nightmare scenario.

    But you know what? Looking at my own professional prospects, I’m not too worried. After all, I’ve chosen to specialize in hospice and palliative medicine. When people’s chronic conditions shatter their lives because they couldn’t afford or get access to treatment, I promise I’ll take very good care of your patients until their last breath. And I’m quite confident that you will be sending those patients to me, because I’m sure that the insurance companies dictating what you could and couldn’t do with your patients will be all too happy to cover my services. After all, the death of someone with a controllable chronic illness may be a tragedy to a family and a loss to society, but it’s a few less negative dollars weighing down that insurance company’s earnings, right?

    The experiment of government-involved healthcare has already been done in other countries for decades, and we have pretty good data about costs and outcomes. Look very carefully at the data before decrying having the government involved.

    Reply

  10. Joseph J

    I am a little concerned by the approach of seeing the doctor as the victim (i.e. if I hear another doctor complain about how much debt they have I might scream).

    As a whole, we as a group have tremendous power/agency in society. I’m not denying that the levers of power impact the work we do, but for many in the population (who let’s not deny have lived life dictated by those in power for generations) do not have anywhere near the income potential as us.

    So an alternative call to action might be, as someone either in or about to enter the ranks of the upper class in America, what are you going to choose to do with your privilege? I for one am happy to give my services (and my tax dollars) in repayment for that which I have been generously afforded. The question at the center of this debate is the same question in the core of our nation: is America a country of “we” and “ours” or is it a country of “me” and “mine”?

    Reply

  11. Beth T

    I believe a part of the solution to containing healthcare costs is cost transparency. It is often difficult to find out how much procedures, labs or imaging cost before ordering them.

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  12. John Cottle DO

    Several of the comments made so far about Medicare For All completely bypass the logical step that if it is completely unaffordable, then existing Medicare must be a failed system. It is, and if you doubt me ask anyone who oversees a facility with a predominantly Medicare population. They MUST have an alternate source of income to make ends meet.

    Europe, Canada, Australia, and New Zealand have successfully met the health needs of their citizens while spending half of what we in the USA do, while having better outcomes data AND better customer satisfaction. Their systems are not perfect, but better than ours.

    It is not easy to admit being wrong, but we Americans need to do so and build a new health care system. Doctors need to lead this discussion, and not just respond defensively to threatened loss of income and/or autonomy.

    Reply

  13. STEVEN M EMMETT DO

    After more than 45 yeas in practice I think a little perspective is in order. As young physicians blame the political system for what is wrong, the blame rests solely on the shoulders of the physicians of my generation.
    It began when we became “providers” instead of physicians. We were now employees of the insurance companies dictating our reimbursements while taking 20% of premiums for profit. We should have come together Instead and refused to accept this model.
    Then one congressman’s wife had a bad Pap smear and we got CLIAj. mandated but not funded by the government. As a result it was funded on the backs of physicians with fees.
    Finally we were conned into EHR’s which were to be the panacea for all our problems. Once again a mandate by the government without establishing a uniform platform allowing the “market” to solve the problems. We all know how well that has worked out. We are constantly told how the data provided by EHR’s are reforming how we care for patients, but are we reimbursed for providing that data? Other entities make fortunes on collecting data and providing it.
    Beginning practice before the insurance industry was making large fortunes cherry picking healthy patients I have seen what medicine has become. Universal health care is the answer with a single formulary and standard reimbursement fees. It will provide basic health care to all without the profit incentive draining valuable resources. Any one wanting “the bells and whistles” of care
    pay for it.

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  14. Richard Toler

    My biggest concern with universal health care is not autonomy. We are already being told what to do by insurance companies.
    I am concerned how the nation would pay for this.
    We would have to raise taxes on working-class Americans for this. Raise them A LOT; to match the contributions of the citizens of the other countries that offer socialized medicine.
    But that would be unpopular.

    I can see our solution being to run up the national debt even more, and pushing the US Government even faster towards bankruptcy.

    To help to manage this the plan would need to cut salaries for the rich parasites profiting off of the system (doctors). I expect that within about 5-10 years; new physicians would be set up with a salary that would be impoverishing compared to their debt.
    (Hopefully those of us who are in practice are cleaning up our finances so we can survive on the 30-50% pay decrease that I am expecting).
    And the people still get to keep their 40% tax rates.

    Reply

  15. Peter M.

    The practice of medicine is a physician’s domain, but organizing a healthcare system is a social issue, and therefore is up to the will of the people given that our country is a democracy. Our place as physicians is to support whatever it is that the people decide and to make the best of it, or at least try not to stand in the way. Certainly we have valuable perspectives that would wisely be taken into consideration, but neither we nor industry stakeholders can justifiably remain in the driver’s seat of policy and expect an outcome that is humane to the majority of citizens.

    I recommend anyone interested in American healthcare debates read or listen to the audiobook of sociologist Paul Starr’s, “The Social Transformation of American Medicine”. It goes all the way back to said debates at the founding of the country up until post-ACA era, if I recall correctly.

    Reply

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