Medicare for All

The ideals of humanism and equality that drove myself and many of my colleagues to choose a career in medicine were slowly crushed during medical school, as we came to realize that the healthcare system in this country consistently fails its patients. Towards the end of medical school, aspiring doctors each choose a specialty to practice after graduation. I chose Emergency Medicine, in part because I liked the idea that we had to treat everyone regardless of whether they had insurance or the ability to pay. This is due to the Emergency Medical Treatment and Labor Act (EMTALA) that was passed by congress in 1986. EMTALA states that ALL patients that present to an Emergency Department in this country must be evaluated to determine if they are experiencing a medical emergency, regardless of whether they are citizens or not, whether they have insurance or means of paying for treatment or not. While the law guarantees screenings for anything that might be immediately dangerous to the patient, that patient is going to receive a bill for that screening, which can sometimes include tests like CT scans, x-rays or other expensive procedures. If the patient does not have insurance, that patient will personally receive the bill. Now if you are fortunate enough to have health insurance, the hospital sends the bill to your insurer, and your insurer decides how much they are willing to pay. The amount the insurer will pay varies widely among different insurance plans. This is where “cost-sharing” comes into play. 

The idea of cost-sharing was developed by neoliberal economists such as Friedrich Hayak and Mark Pauly in the mid-twentieth century 1. It was supposed to be a solution to what they called the “moral hazard” of free health care. The thinking was that if people did not have to pay to see health care providers and go to the hospital for an emergency, they would use TOO MUCH health care, and that would increase spending by insurance companies, and more importantly for the neoliberals, lower their profits. The thinking went that if insured patients had to pay out of pocket to access health care services, they would be less likely to seek attention for “nuisance” or “sniffle claims” 1. 

Support for cost-sharing came from a government-funded observational study from the RAND corporation in the 1970’s called the HIE (Health Insurance Experiment). 2,750 families were divided into 5 different groups. One group had to pay nothing to access health services and the other four groups had increasing percentages of cost-sharing. After ten years of this study, the health outcomes and spending were compared across the groups, it was unsurprisingly shown that as the patient’s burden of cost-sharing increased, they went to the doctor less often. What really cemented this study as foundational to cost-sharing was that it demonstrated equal health outcomes among all five groups. In most cases, a lifetime is longer than 10 years, and it often takes more than ten years to see the worst effects of high blood pressure, obesity, high cholesterol, diabetes, alcoholism, cigarette smoking. 

Another central finding of the RAND HIE study was that all levels of cost-sharing reduced both “appropriate” and “inappropriate” use of health care services. The problem with labeling the use of health care services as “inappropriate” is that uncertainty is what drives most people to visit their providers. For example, “I’m having chest pain, is this a heart attack?” or “I’m dizzy, is this a stroke or just an ear infection?” It can only be determined if these are appropriate reasons to seek care after a medical evaluation has been made. Cost-sharing encourages people not to take their own symptoms seriously out of financial concern. It leaves people afraid to seek the care that they need:“This headache keeps getting worse, I hope it just goes away because I can’t afford my co-pay to go to the ER.” 

A common reason for people not to use their health insurance, even when they have it, is a high deductible. The deductible is the amount of money that you have to spend out of pocket before your insurance begins to contribute to the services you receive. The less money that you pay for your premium (your monthly bill, or tax, to remain insured), the higher the rate of your deductible is likely to be. The average deductible for an employer-sponsored health insurance plan is $1,491 for individuals and $2,788 for families, but 23% of employer sponsored family plans have a deductible higher than $5,000 2. When you compare this to the fact that more than 60% of American households do not have the savings to cover a $1000 emergency, it becomes clear that these plans are designed not to be used 3.

As consumers in this country, we are bombarded with different choices and options for any product we wish to buy. When President Obama was promoting the rollout of his health insurance marketplaces, he said that choosing a health insurance plan would be like shopping for a “plane ticket on Kayak, or a TV on Amazon”.  Although there is preventative medicine, such as health screenings and vaccines, most people’s interaction with the health care system are unplanned. When you choose which health care plan to buy for yourself or your family, unlike a TV or a plane ticket, you hoping that you do NOT have to use it. This is not the kind of decision that people want to make. 

It might sound like I understand this health insurance racket pretty well. In reality, I also stress out about which level of cost-sharing I should risk when I choose our family’s health care plan for the year. Having to choose which degree of risk that you are willing to take on in regards to the health and possible life-ending illness or accident that may happen to your family member is  an obscene form of gambling. The cheerful nature in which you are provided with the freedom of choice between any number of plans that may leave you unable to “access” your health care resources because you do not have the ability to pay $5,000 out of pocket without taking on a debt is infuriating and designed to confuse people. With bronze, silver, gold, and platinum levels, it certainly sounds like we are all winners for being the owners of a worthless product. Some neoliberal executive probably got promoted for making us feel good about winning a consolation trophy for the lack of coverage we just got. The reality is that private health insurance provides you with no actual health care services. Maybe we can count that email that they sent you with a link to a smoking cessation calendar. but the main function of private health insurance is to restrict your access to health care services.  

During discussions about health care, people who have insurance through their employer often think or say that their employer “gives” them their health care. The employers GIVE us nothing. If you look at your paystub, you will see that there is a deduction from your paycheck to cover your health insurance, effectively a tax. It’s less money than you would pay on the Obamacare marketplace, but you are still paying for your health insurance, you just share the cost with your employer, who can change your plan or the amount that you are supposed to contribute without your consent. If your plan becomes too expensive, they will recommend you choose a cheaper plan, one that has a higher burden of cost-sharing. The cheaper the monthly premiums for a plan, the higher the amount of cost-sharing will be and a lower number of covered services.  

Since the end of World War II, every Democratic presidential administration has made an attempt to provide universal health care to the people of this country, and although many gains have been made, all have fallen short and millions remain without any health insurance. Others, in the event of a true medical emergency, realize that they are underinsured. The corporate interests opposed to universal health care are powerful and universal healthcare represents such a threat to their profits that their lobbying groups such as AHIP (American’s Health Insurance Plans), PhRMA (Pharmaceutical Researchers and Manufacturers of America), the Biotechnology Innovation Organization, and the American Medical Association, the largest association of physicians in the country, spent over $143 million in 2018 alone to prevent Medicare for All 4. The private health insurance industry is seriously committed to maintaining the current system, and have weakened or outright defeated all political attempts to stop health care from being a profit-driven rather than an outcome-driven industry. 

In order to defeat these corporate giants it will take a national movement behind a candidate who is not just interested in making this change, but one who is salivating for this particular fight. The industries that currently profit off of the inhumanity of our current system will spend millions of dollars on advertisements and talking heads who go on television and say universal health care is a step towards socialism. Although memories of this strategy are fresh from the struggle to implement the Affordable Care Act, it is the same strategy that was used to defeat President Truman’s universal health care plan in 1945. The forces that are aligned to deny us universal health care are too powerful to be beaten by just one candidate or just one election. We need a candidate who will champion this cause, but we must all stand up and demand it.

When a government program is universal, everyone in the country has a reason to defend it, and hold their representatives accountable if they try to defund or degrade it. Once health care becomes a common good, it will be possible to organize people across all ages, races and income levels to defend it. For over seventy years, incremental attempts to provide more Americans with health care through means-tested programs has been a failure that leaves millions uninsured, and millions more with a health insurance plan that can still leave them bankrupt if they get sick. 

There can be no compromise with the private health insurance industry. Health care is a human right, and it must be provided to everyone without cost-sharing. To make this happen, we need to call for an end to private health insurance, which has become bloated from the profits of our sickness and misery. As a physician, I never want to hear, “I can’t afford my insulin, so I’m just using less” or “I’ll take my chances with this chest pain, I don’t have the money to pay for my deductible.” The only way for this to happen is to enact universal health care.

Among the presidential candidates for 2020, Senator Sanders wrote the current Medicare for All legislation, which would provide universal health care and the end private health insurance industry, to be funded by a payroll tax. Senator Warren co-sponsored the bill, but as of 11/1/19 has proposed a very different means of financing it, which would require the passage of immigration reform. Senator Booker and Representative Gabbard have both co-sponsored Medicare for All legislation, but have not committed to ending private health insurance. Vice President Biden, Mayor Buttigieg, Senator Harris, Secretary Castro, Ms. Williamson, Mr. Yang, Mr. Steyer, and Senator Klobuchar have all supported the creation of a public option, but state that there is still a role for private insurance. https://www.npr.org/2019/09/10/758172208/health-care-see-where-the-2020-democratic-candidates-stand 

In early November 2019, Senator Warren released her plan to fund her proposed Medicare for All. Bernie Sanders also has a plan for funding his longtime Medicare For All vision. The fact that two of the leading presidential candidates are willing to champion universal health care and end private health insurance in this country is a remarkable step forward for the movement. However, it’s important to take a closer look at how each candidate plans to implement it. 

The Warren plan is to put a public option for health insurance in place, which people could choose to sign up for, within her first hundred days in office, but to only introduce Medicare for All legislation in the third year of her presidency. This is problematic and here’s why. Passing Medicare for All legislation will be an enormous battle, as every Democratic president since Truman has attempted to put forth a form of universal health care only to be defeated by spending on advertising and political contributions from the pharmaceutical industry, private health insurance companies, and physicians’ groups such as the American Medical Association. Presidents since 1946 have lost an average of 25 seats in the midterm elections two years after their own election (https://news.gallup.com/poll/242093/midterm-seat-loss-averages-unpopular-presidents.aspx) . To succeed where past presidents have all failed, it would make sense to try and pass Medicare for All with the maximum number of Democratic seats in congress, early on in the next Presidential term. Openly declaring that she will not try to pass universal health care legislation until the third year of her presidency indicates that Warren may have a lack of ambition to win this fight.

Let’s take a look at Sanders’ plan. Senator Sanders openly states that the funding for his Medicare for All program will come from a payroll tax. This is how Social Security and Medicare are currently funded. As of 2019, an employee has 6.2% of every paycheck withheld to fund Social Security (https://www.irs.gov/taxtopics/tc751). This tax is described as progressive, because the higher an employee’s take home pay, the more money they pay into Social Security. Medicare and Social Security are extremely popular programs and Americans understand how they are paid for because they can see it on every paystub. Senator Warren has gone to great lengths to say that her funding plan will not cost middle class Americans any additional money in taxes (https://www.businessinsider.com/elizabeth-warren-not-one-penny-tax-increases-medicare-for-all-2019-11), however her funding plan is very complicated and makes several risky assumptions. On her website, Senator Warren states that one of the four sources of funding will come from the passage of immigration reform (https://elizabethwarren.com/plans/paying-for-m4a), but despite many efforts, immigration reform plans have not been able to pass both the House and the Senate for more than 30 years. If a Warren immigration plan stalls in congress, does this mean a further delay in the implementation of her health care plan? 

Additionally, rather than a progressive payroll tax, the Warren plan proposes to charge employers a regressive “head tax” of $9,500 dollars for all employees (https://slate.com/business/2019/11/elizabeth-warrens-health-care-medicare-for-all-single-payer-unfair.html). This tax is described as regressive because employers would pay the same amount per employee, whether the employee earned $25,000 a year or $250,000 a year. Making business owners shoulder the load of paying for this program will only broaden the coalition that opposes Medicare for All. In an effort to avoid paying this head tax, some employers are likely to change the status of their employees to independent contractors, a loophole that has been exposed by bad corporate actors such as Uber and Lyft. 

Passing universal health care legislation will be one of the greatest political struggles of this generation, one that will require supreme urgency and a sober understanding of where and how the opposition will attack us. Senator Sanders has stated that he will introduce Medicare for All legislation within the first week of his presidency (https://thehill.com/policy/healthcare/470745-sanders-vows-to-introduce-medicare-for-all-in-first-week-of-presidency). He also trusts the American people to understand that progressive taxes paid by all is how popular government programs are funded in this country. These facts are fundamental to our coalition if we are to gain the basic human right of healthcare for everyone in this country.