Another crosspost from our med school Health Policy student group’s blog. I wrote this around a month ago, so some things may feel out of date–definitely need to keep thinking about this, as I’m certain my thoughts will continue to evolve.
With Trump in the White House and a Republican-dominated legislature, it would take a sharp twist of fate for Bernie Sanders’ Medicare-for-All bill to become law anytime soon. Still, it poses a thrilling proposition: under the single-payer plan, private insurance would be virtually abolished, healthcare would be mostly paid for by the government, and all Americans would be insured. Benefits would be generous, including dental, vision, substance-abuse treatment, and reproductive care.
The plan would also facilitate concerted drug price negotiation, helping us oust our ignominious title of paying the most per capita on prescription medications of all high-income countries. For a country that pays $10,000 per person on healthcare—double that of peer developed countries with universal health care, despite attaining equal to worse health outcomes—any price reduction would be welcome.
Single-payer advocates draw from an underlying assumption: by providing health insurance to those who can’t afford it, we can improve their wellbeing. The dogma is more contentious than would first appear, with some politicians proclaiming, “Nobody dies because they don’t have access to healthcare.” Fortunately, a formidable body of health economics research serves as rejoinder.
For one, the randomized Oregon Medicaid study found Medicaid receipt cut $390 from medical bills, increased diabetes diagnoses and treatment, reduced depressive symptoms, and drastically improved self-reported health, a validated predictor of mortality. Though this study found no impact on most clinical measurements after two years, a larger, five-year study compared certain states implementing Medicaid expansion to neighbors who didn’t, and found adjusted all-cause mortality dropped by 6%. It stands to reason that effects of insurance on health may be slow, especially if rooted in increased regular preventive care and chronic disease management.
Nevertheless, the bill has raised several compelling criticisms from across the political spectrum. One is that Sanders’ proposal is unrealistic, as it does not define how the government would raise money to fund coverage.
But if this year taught us anything, it is that political rallying cries can mobilize masses, whether or not they are bolstered by evidence or well-designed plans. While this phenomenon is maddening when the rabble-rousing, say, incites xenophobia or pretends climate change doesn’t exist, it cloaks an intriguing psychology. Something like: the public is agitated to productive action when a public figure echoes their inner beliefs, confirming to them that their thoughts deserve to be broadcast and implemented.
Thus, the lack of details doesn’t necessarily strip the bill of its teeth. I enjoy ideating a world where healthcare is universally available; if this gets the rest of the country to even countenance that idea, it signifies progress. And so it has: the bill is cosponsored by 15 Democratic senators, including rumored 2020 candidates such as Elizabeth Warren and Cory Booker. The Pew Research Center reports that 60% of Americans believe the federal government should provide health coverage for all Americans, the highest level in almost a decade; the bill arrives in time to galvanize Democratic voters before the 2018 midterm elections. Moreover, the projected price tag of $32 trillion over ten years, despite the revulsion it has induced in many a Republican, is $17 trillion less than the projected cost of the current system. Shifting that money from private to public sector would require creativity, but as Paul Waldman reminds us, “Single payer is many things, but above all it is cheap.”
So why am I not excited?
In short, the buzz around Sanders’ bill feels premature. Margot Sanger-Katz from The New York Times has called “single payer” the Democratic catchphrase equivalent of “repeal and replace.” Even if they have intrinsic differences–as Clio Chang counters: “Repeal and replace was a cynical, partisan reaction to Obamacare, whereas the push for single-payer is rooted in a moral imperative to improve the lives of all Americans”—neither reflect the thorny implementation questions embedded within them.
For single payer, those questions are crucial. As mentioned before, one is: how do we convince people to pay taxes to fund coverage? But the crux behind this challenge, Chait argues, is not that people are reluctant to aid the uninsured. Instead, it is that 55% of Americans currently receive, and in large part are satisfied with, employer-paid health-care. They comprise a substantial voting bloc that must be persuaded to accede to not just tax hikes, but also dramatic alterations to their coverage. Politicians endorsing the single-payer bill have tied themselves to all of the upsides, but must rigorously grapple with these downsides—ones that have constrained reform efforts for decades.
On the other hand, single-payer is not the only way to achieve universal healthcare coverage. Ron Pollack details several “incremental” methods he deems both politically feasible and progressive: expanding Medicaid in states that have not yet done so; remedying the “family glitch” of the ACA, in which ACA assistance eligibility is determined by an individual worker’s insurance costs instead of those of their family; ensuring a funding extension for CHIP; bargaining for lower drug prices; and establishing public insurance plans in low-competition areas, to name a few.
America faces a unique set of circumstances that sets it apart from any other nation, not limited to entrenched employer-based health-care, acrimonious partisan battles around the Affordable Care Act, and exorbitant healthcare and medication costs. We need equally unique policies that acknowledge these circumstances, and offer revolutionary, viable solutions to ensure nobody suffers for inability to afford healthcare. With healthcare conversations at the forefront of today’s political conversations, I hope these solutions come sooner rather than later.