Opinion

Medicare for All: Worth fighting for

The osteopathic profession has a proud origin, based on casting out a health system that was known to be harmful. This is a similar fight.

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.

Several medical students recently published editorials in The DO concerning proposals for a single-payer health care system, evidence that future graduates sense our health care system is in crisis. Their generation has the burden of building something new and they understandably struggle with what this new system will be.

As physicians, our patients and the nation look to us for leadership. If we are to honor this profession, we need to unite around the facts, using our education and experience to be open-minded, selfless and visionary.

Powerful forces divide us

First, let’s agree that our current system is in crisis. In 2016, health care spending was 17.9 percent of GDP, and it is projected to rise to 19.7 percent by 2026. Employer-sponsored insurance health spending increased by 44% from 2007 to 2016, which contributed to wage stagnation and shifted costs onto employees. Roughly a quarter of American households are struggling with medical debt.

James Adams, DO

Despite partisan changes in 2010 and 2016, 12 percent of Americans are uninsured, while many insured Americans face ominous deductibles, restrictive networks, surprise bills and unaffordable meds. Physicians are forced to ask permission of insurance companies prior to many procedures. Pharmaceutical companies are allowed to advertise directly to patients, providing “education,” while drug profits and overdose deaths skyrocket.

Can life expectancy be viewed as an overall health system score? Ours, currently 78.6 years, has declined two years in a row, ranking 34th among nations, according to the WHO.

A system in crisis justifies revolution

Our basic problem is shared by peer nations, who have almost all met that challenge by providing universal health care. The United States stands alone, hanging on to our antiquated for-profit, multi-payer system. It is foolish to judge all those countries as wrong while they have better overall results at half the cost.

A single-payer system will massively reduce administrative waste, saving an estimated $500 billion annually, while the ability to negotiate drug and device prices on behalf of 320 million would cut costs even further. A paradigm shift from crisis care to preventive care would also be more cost-effective, resulting in additional savings.

Many fear a single-payer system will restrict access to care. Canada’s single-payer system has wait lists for elective procedures because they choose to balance between need versus spending.

Listen to the patients

A recent Reuters poll revealed 70 percent of Americans want comprehensive Medicare for All.

The current Medicare for All bill would provide primary care and prevention, approved dietary and nutrition therapies, outpatient care, full dental (including oral surgery), basic vision and vision correction, prescription medications, hearing services and hearing aids, podiatry, diagnostic services, emergency care, inpatient care, durable medical equipment, mental health services, substance abuse services, long-term nursing home care and palliative care—all with no deductibles, copayments or coinsurance required from patients.

The myriad ways this single-payer system could be paid for are outlined here. Of note: Ninety-five percent of American households would come out financially ahead under this plan, and any new taxes would be modest, progressive, and offset by the absence of high premiums and numerous out-of-pocket expenses.

Medicare for All is health-centered and transparent

A single-payer system creates a national insurance that is publicly funded, while care delivery remains private. Treatment decisions will be made by clinicians and patients, instead of profit-centered corporations or legislators.

Decisions regarding payments, formularies and best practices will have public accountability and transparency. This democratic process would involve regional, state and national boards comprised of health care professionals, representatives of health care institutions, health care advocacy groups, labor unions, and citizen patient advocates. None would be allowed to have a financial conflict of interest.

The osteopathic profession has a proud origin, based on casting out a health system that was known to be ineffective and often harmful. This is a similar fight … and it is our time to lead.

Further reading:

Medicare for All equals quality health care for none

It’s time for a single-payer health care system in the US. Here’s why.

Forget single-payer: Let’s focus on personal responsibility

31 comments

  1. You are seriously mistaken if you believe that a government run single payer system is in the best interest of our health care system and more importantly our patients.
    Just ask our Canadian neighbors.

    1. I have asked, and the few I spoke with are proud of their system. They agree it isn’t perfect, but much better than ours. I have also attended CME conferences taught by Canadian physicians.

    2. Dr Borin – I know you and respect you a great deal. So I VERY carefully ask you to consider facts / references to the contrary. In a 2004 nationwide survey of Canadians, Tommy Douglas (father of their single payer system) was voted their “Greatest Canadian” (https://www.huffingtonpost.ca/marvin-ross/to-the-americans-doubting-universal-health-care-it-saved-my-life_a_23219381/).
      Despite conservative governments over the years, it is political suicide for any politician to suggest doing away with their medicare system (https://www.huffingtonpost.ca/marvin-ross/to-the-americans-doubting-universal-health-care-it-saved-my-life_a_23219381/).
      As for “government run” – that’s propaganda designed to create fear or controversy. State and fed government interference today is the product of crony legislators – who, instead of representing patients and healthcare – do the bidding of insurance & pharma lobbyists. Our single payer system will be run by regional, state and national boards – representing the best interests of health and nation. The only thing “government run” is that they collect the taxes to fund our national insurance (https://www.congress.gov/bill/115th-congress/house-bill/676/text#toc-H1AA33722963248B39F8F6E56EE74BD70).
      As for “best interest of health system and patients”, universal coverage is better than ~30 million without – fully comprehensive care is better than the denial policies we now have – eliminating waste is better than out of control spending.

    3. Canada has superior health outcomes, for fewer dollars per capita. There is a net flow of physicians INTO Canada annually ( a reversal of the situation some decades ago ). This is thought to be driven mainly by dissatisfaction with practice in the US, struggling in a multi-payer system, and with seeing patients barred from appropriate care by for-profit insurers.

      Your assertion warrants evidence and data.

      1. Most of the differences in healthcare outcomes between the US and others come down to the difference in overall health – our country is heavier, more sedentary, and more “nourished” than any on earth. That’s not a health care problem, it’s a personal care problem.

        Worst of all, we have to stop acting like someone else is responsible for paying for a lifetime of poor lifestyle and health choices of another. No one forced you to smoke, eat the Twinkie, or use your home gym as a laundry hanger. As people and as free individuals, we all need to be held accountable for our own actions/inactions.

        As physicians, we cannot continue to conflate problems with health insurance with those of healthcare. They are not the same. The first step to correcting the issues are to get the government out of healthcare, not more involved. Read about crony capitalism.

    4. I have, including the few Canadian doctors I know. While admitting its flaws, they are overall satisfied with their care. If you believe that the current US system is in our best interest, ask more of our patients!

  2. Benefits to consider with Medicare for All:
    1. Decreased risk pool by addition of younger healthier patients
    2. Competition for major insurers. Remember these companies do not lose money insuring patients
    3. Eliminating obscene salaries for CEOs of insurance companies and hospitals executives
    4. Reimbursing companies that agree to use Medicare plans for employees
    5. Simplified payment for healthcare providers
    I’m sure there are many more benefits than outweigh risks to implement what has been proposed by this interesting editorial.

    1. Dr Agostini – I like the way you think:
      1. Re risk pool and the way insurances work – the more that pay into an insurance, the less volatility, and the greater bargaining power. There can be no more . . . than everyone – pooled into a single national insurance. Just imagine the collective power to bargain for drug prices.
      2 & 3. Competition among private insurers will be limited to policies outside the scope of our single payer (cosmetic surgeries, private beds, etc).
      4. Companies no longer have the overwhelming cost and burden of providing health insurance. So, they can concentrate on doing whatever business that they do best – and put their money into growing their company. It makes them globally competitive, with businesses in other countries that don’t have this burden.
      5. Most hospitals employ more people to handle billing, than they have beds in their hospital. Watch Fix-It, and enjoy the part regarding how Canadian hospitals bill (https://fixithealthcare.com/).

      1. Richard,
        Think outside the box re #4, and consider the possibility of offering “vouchers” to companies that would help contribute to their employees’ Medicare coverage.
        I’m retired and on Medicare and feel it’s a great system. Never thought as a physician that I’d ever support single payer, but we’re the only developed country that supports this crazy health insurance model and its inherent unbridled costs.
        Dennis

  3. Does this mean that I get all my medical bills that I payed over the years including health insurance premiums reimbursed under your new system? I think those are called preexisting expenses. :-) Fair is Fair

    1. Medical debt humor. Who’d have thought.
      . . . I like it, Dr. Oswald.

      No. But what you do get, is freedom from this: “Smaller practices spend an average of $83,000 per year on claims, coverage and billing. Doctors personally spend nine hours each week on billing and admin; that’s time we’re not seeing patients. It’s no surprise that doctors today report unprecedented levels of exhaustion and burnout.”

      https://www.commondreams.org/views/2018/09/11/medicare-all-and-myth-40-physician-pay-cut

  4. After practicing for over 45 years, I can certainly agree that a single payer system could/would be beneficial for our (used to be) cottage based separate medical practices. This is rapidly decreasing due to increasing corporate practice of medicine and employed physicians. That being said, let’s figure out how to get the for-profit big insurance companies totally out of the health care system. If you remember , when managed care was touted to be the “new and better” way by a certain POTUS’s wife, the insurance’s companies profits went up and physicians income went down. Also, when the “Affordable”Health Care was crammed down our throats, the American people (in toto) suffered….sure there were more covered, but less could afford the increasing premiums….it is and was a failure. BTW, most of the big insurance companies “paid” for a seat at the POTUS table and look who came out on top.
    I would certainly encourage a single payer system, maybe even Medicare for all (with strong physician input)…..but first get the for-profit insurance companies out of the equation.
    Thank you,
    Would appreciate any comments by the author.

    1. Comments by me . . . definitely!

      You mention a great point regarding corporate medicine / employed physicians. This is just one example of for-profit health insurances buying our practices (https://www.nytimes.com/2017/12/06/health/unitedhealth-doctors-insurance.html). The analysis of this isn’t rocket-science. Their motive is quarterly earnings and dividends – and to that end, physician autonomy goes down. As money is funneled to them – it is diverted away from provision of health care.

      As for others touting managed care being a “new and better” way – I would look farther back. Nixon signed the HMO act about the same time Canada fully launched its single payer system. Prior to that, our health spending and outcomes were similar. However, that was the fork in the road. The slope in their curve changed at that point – and Canada has exceeded us in most health outcomes, at almost half the cost (http://www.pnhp.org/news/2017/may/canadian-vs-us-health-care). Nixon fell into disgrace – while Tommy Douglas (father of their medicare) was voted by Canadians their “Greatest Canadian”. Versus our current system in crisis.

      I absolutely agree with you regarding failure of the PP-ACA. When the root of the problem is the for-profit insurance industry and big Pharma – you don’t fix the problem by literally allowing them to write the act, forcing nearly everyone to buy their product, and keeping them at the forefront of our system. Instead – you cathartic them out the anus of our system.

    1. Hi, Alan. You’re quoting Mark Twain, and I’m just a short drive from Hannibal.
      Twain was conservative, and hated Teddy Roosevelt’s trust-busting. However, monopolies can be harmful – because they often lead to crony-capitalism. Capitalism is foundational to the U.S., but cronyism removes the balances of capitalism.
      The insurance lobby and big pharma have used cronyism to virtually exercise a military siege on our profession, and we’re losing.
      We’re in a fight that is non-partisan. It should all be focused on, what is the healthiest health-system, with the most efficient costs.

      Here are some stats: The U.S. spends nearly 18% GDP on health spending – versus Canada’s 10.4%, or the U.K.’s 9.7%. Most health outcomes are better in countries with universal healthcare using a single payer of one form or other. (https://data.oecd.org/ Click on “database access”, then on the left column click “health”)

      If you haven’t already, I encourage you to watch,”Fix-It” ( https://fixithealthcare.com/ ).

      Thank you, sir

    2. If you dont trust statistics then what information do you trust? Merely curious. Seeing as the profession you went into relies heavily on using treatments and methods that are drawn directly from statistical data.
      Side note: I am from Hannibal and Mark Twain was a phenomenal writer but a horrible physician.

  5. More patient education will be needed to stop wasteful use/ abuse of our ERs and urgent care centers as we all have noted happening on a daily basis to provide a higher level of care and more importantly contain its cost.

    1. Hi, Dr Green. I agree.

      Moving to a single payer system such as H.R. 676 removes deductibles, co-pays, co-insurances, spin-downs, doughnut holes / sometimes astronomical drug prices, etc . . . the barriers that prevent so many people from seeking care when they should (and then wind up in the ER or urgent care, like you mention).
      Instead of our crisis-care system – can you imaging the paradigm shift, of a system designed for health promotion, early mitigation, and efficiency?

      Thank you for the good comment

  6. An easy call for anyone outside the US. Universal care, free of profiteering private interests is an essential component of resolving economic and social inequities that are increasingly crippling our country.
    I have often wondered if they removed medicare-style fee restrictions on balance billing if patients might get what need and cream of crop of physicians could still rise. When I was growing up you, “went to the doctor you could afford”.
    In 2012 I was keynote at Canadian Assn. of Orthopedic Medicine meeting. Docs were abandoning their interest in OMT bc government changes in reimbursement. We are close to having our medicare cut wiped out for OMT as well. I dropped them years ago after auditing threats due to constantly changing interpretations of billing OV, -25 modifier with procedure code, etc. (I owed them $75 after 6 month investigation). I would be a fool to return to taking government money, yet private insurance quit paying for OMT years ago in PA.
    I would encourage doctors to show more courage and quit playing the patsy for our competing and controlling interests including gov’t, insurers, hospitals and big pharma

    1. “resolving economic and social inequities that are increasingly crippling our country” … . Wow. Is it a goal to have these inequities leveled so that everyone is “equal”? Same cars, houses, etc? Sounds like Socialism, which doesn’t work. Society — that is, people with jobs and paying taxes — should provide a temporary safety net, but not a permanent way of life/lifestyle. Certainly a case by case basis. Too many able bodied people are gaming the system. We cannot continue to punish society at large for recurrent poor choices by a significant percentage people taking advantage of the system. In summary, many of these “inequities” were driven by poor choices and should not automatically be put on the backs of the tax paying public to cover the “my bad” consequences. This sentiment, of course, both includes and goes beyond the health care issue. Just my 2 cents.
      #medicalnoncompliance
      #personalchoicesmatter

      1. Hi, Richard.

        I’m not sure what you truly believe. I don’t know you, but I don’t think you believe that having a single payer national health insurance – will plummet us into Marxism, any more than having a public fire department does. It’s simply a need that we all share, and it is better to have a public fire department, than to sell restrictive fire insurance policies.
        Similar argument could be made for having city police departments, or national parks, or other public programs.
        I don’t want to live in a nation that offers nothing.
        If you look at this list of the top 10 happiest countries in the world – you won’t find the United States. What you will find, are several peer nations that have various public systems to promote their middle class and provide safety nets in times of need. And, that includes universal health care – not having to worry that the doctor’s visit or test that they’re putting off, will lead to a delayed diagnosis or to a medical bankruptcy. (
        https://www.nationalgeographic.com/travel/top-10/2016-worlds-happiest-countries/ )

        The idea that single payer is some attempt to have everyone have the same car, same house, or whatever . . . I don’t think you really believe that.

        As for people exercising good lifestyle choices – a single payer system is well suited to promote that – though strengthening public health programs, better screening compliance, better communication. Health outcomes are better in peer nations w/ single payer

    2. Dr Laseter,
      I value your insight. I’m in a similar boat. I only perform / interpret MRI – and if I were only to have CMS payments for all exams that we do, we’d have to shut our doors immediately. Instead, other insurances throw us an extra bone (that’s an orthopedic reference, by the way). Which keeps us open, but starved.

      In H.R. 676, reimbursements, etc, will be determined by regional, state and national boards – with the best interest of promoting patients and our health system. If there is a problem in the system (reimbursements being one example), there is a democratic process to address it. That is contrary to now – where these decisions are behind closed doors of CEOs or congress.

      I encourage doctors, and everyone, to look to at what our peer nations have already done (which is universal healthcare, most having done so with a single payer of one form or other) – learn from their mistakes – and build a single payer system that is uniquely ours and truly to be proud of.

      (Thank you Dr Laseter)

  7. Then why not have a reasonable monthly premium like they do in Canada and Switzerland? That would generate some of the revenue. I know in some countries there are small copays for prescriptions too.

    1. Hi K,

      The “skin in the game” concept is discussed a lot. However, they pose problems:

      One is, that it is expensive to track these copays and other out of pockets – and to deal with those who don’t comply. It takes away from the administrative simplification and savings that will save ~$500 billion annually – and we don’t want that.

      Another is, that even small cost-sharing like you mention, result in people not showing up for care early when they need it – even folks making higher incomes. Then we start dealing with issues of delayed diagnosis and avoidable hospitalizations – with the subsequent cost being higher than the revenue benefit that you were mentioning.

      As for other people’s argument that skin in the game will prevent freeloaders from showing up at the doctors’ offices all the time. There’s no evidence in other countries that this happens (At least I’ve seen no peer-reviewed evidence of it). People show up when they need to. But in general – when folks have a day off, they find more fun things to do than go to the doctor’s office.

      Thanks for the comment. It’s a good discussion.

  8. As someone who takes Medicaid primarily and still in private practice, I often think that these ideas build steam when physicians give up their autonomy in the first place by allowing themselves to be “employed” by a buisiness person in a suit who doesn’t know a thing about actual healthcare. Certainly fighting for every penny is annoying, but giving up all ability to bargain and fight is not good either. Medicaid makes huge mistakes already…..forget to pay for well visits in first year of life, not reimburse for required vaccines, tell us who we are allowed to check a hearing test on, tells us how many people a month we can refer to specialists, tells us what medicine we are allowed to prescribe due to cost for them, tells us they will pay $13 for any OMT, etc. etc. etc. Physicinas need to go back to being in charge of patient care. Did anyone notice how one big perk of this article was that patients should now come to see a doctor every month? Can you imagine being that patient? They already can’t find time to come quarterly and they don’t have jobs that allow time off for doctor visits! Also, if we cut the number of patient visits, although that sounds nice, that means half as many people have access to their doctor a day. That’s not good for patient care either!

    1. Well, I’m not sure where to start with this.

      You seem to be describing managed care (like HMOs, etc) or corporate purchasing of physicians groups – and the losses of autonomy. Or the non-negotiable oppression upon patients and physicians within the contracts of for-profit insurances. Or the problems of medicaid – which is largely state-controlled, so it varies from state to state – and common people have very little ability to change or improve it.

      The cure to all of this, is moving TO single payer – not away from it. Control shifts away from corporate board rooms and secret rooms in congress (to maximize profits, or to make deals) – and toward transparent regional, state and national boards (making decisions based on what is best for healthcare, at the most efficient cost).

      This article said nothing about “a big perk that patients should see a doctor every month”. Goodness! However, since you brought it up. If you look into number of doctor’s visits per patient per year – you’ll struggle to find more than in Japan. And, the Japanese have the highest life expectancy of any of the OECD nations. They have a national insurance, and spend only 10.9% GDP – versus our outrageous spending and poorer outcomes.

      I agree – lets move toward greater autonomy, and what’s good for patient care. All other peer nations have done this through universal health care, and most have utilized a single payer of one form or other. We can take their experience, improve it, and start building pride

  9. More Government involvement in anything just grows the bureaucracy. The government can’t get out of its own way. We could decrease healthcare spending in general by cutting the number of administrators in half and significantly reducing the EMR burden on physicians thereby allowing time to see more patients … . Reducing Government involvement should be the goal. It was never intended by the founding fathers to have the Government involved in every aspect of our lives. Where does it end?

    1. Hello, Dr Pearson. I agree with your view that government is in the way, currently. However, under H.R. 676, its main role is to collect the taxes that fund our new national insurance – and they’re pretty efficient at doing that. In the meantime – it’s not the government, but rather, is regional, state, and national boards that determine things like whether fee schedules are fair, or whether evidence supports keeping or not keeping meds in the formulary – or other specifics of the like. As in the article, the boards are comprised of health care professionals, representatives of health care institutions, health care advocacy groups, labor unions, and citizen patient advocates. None would be allowed to have a financial conflict of interest. So – government involvement is low, and public accountability is high.

      As for cutting administrators – single payer massively does that. $500 billion worth / year.

      I notice that you are a lawyer – which begs the topic of malpractice issues. Currently, a large part of settlements are to cover current and future medical expenses for individuals. Under Medicare for All, those expenses are gone. Settlements should significantly decrease, as should malpractice insurance premiums. Also, medical errors should go down – as our system becomes less fragmented, patients are switching doctors less frequently, and communication improves (one national EMR will be developed – making communication of records / ancillaries more open), etc.

      Thank you, sir.

  10. Thank you for taking the time to write this excellent editorial, Dr. Adams. As a medical student, I found some of the recent editorials written by my colleagues disheartening. Single-payer healthcare works well in every other developed country on Earth and it is foolish to think that America is “exceptional” with regards to our current health system.

    If you walk into the headquarters of the United States Department of Health and Human Services, there is a quote on the wall by Vice President Hubert Humphrey, whom the building is also named after. It reads “the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.” I am encouraged whenever I encounter other medical professionals advocating for a return to morality in the US healthcare system and hope that many more will be inspired to join us.

  11. Insightul and intelligent article.
    I am not that old, but I do remember the 1950’s and early 60’s as a child in regards to Canadian phyisicians (they were clamouring to come here). Now the reverse is true. For those whose main fear is the loss of income you should check out the income of primary care physicians in Canada and U.K. and you would be surprised at the miniscule difference in income with U.S. (not counting the grief, overhead and financially dead time you spend re insurance issues.). Check with the populations of these countries to see if they would want to switch to our great system.
    In addition you shouldn’t be surprised at the benefits to the economy as a whole. The workers in Germany and Japan aren’t any better than the workers here. Employers there don’t spend significant amounts of their cash flow for substandard health insurance. It far outweighs any tax burden they face.
    Also, dental care in this country is a disgrace. Aside from insurance reimbursement which is a disgrace, placing even rudimentary care beyond the reach of the majority of people, dentist income is far outweighed by the minimal work schedule (now less than 5 days a week) and virtually no call (worse case phone call if it sounds bad enough: “go to the ER”).
    Of course it would take tax dollars to pay for this. But considering the enormous waste of our current private system, they pale in comparison.

  12. I am first year medical student at ATSU and I wanted to say that after reading this article I feel very optimistic about the future. The current health care system in the U.S. is undoubtedly broken and a single-payer health care system is the reform we need.

    “If we are to honor this profession, we need to unite around the facts, using our education and experience to be open-minded, selfless and visionary.”

    Very inspirational!

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