David Brooks in his column, “‘Medicare for All’: The Impossible Dream,” (New
York Times, March 4, 2019) argues that regardless of the appeal of adopting
Medicare for all, the U.S. transitioning to Medicare for all is impossible.
Brooks is partially correct. Transitioning from the current mélange
of health care insurance programs to Medicare for all will be exceedingly
difficult. However, the difficulty in transitioning is an insufficient reason
for not moving forward.
First, health care is a basic human right, a basic corollary
of the right to life. The right to life is corroded by selfishness and greed
every time somebody’s life is cut short or somebody’s quality of life is
substantially diminished by a preventable or treatable condition for which the
person could not obtain the required health care. Studies consistently show
that people in the U.S. have shorter life expectancies and live lives impaired
by more preventable or treatable conditions than do residents of other developed
countries. In other words, Americans enjoy the right to life less than do
people in other developed countries in spite of spending more on health care
per capita than do people in any other country. Refusing the challenge of
transitioning to Medicare for all permanently condemns Americans to enjoying an
unnecessarily limited right to life.
Second, a huge number of people associated with health care currently
produce little of real value: everyone connected with the health insurance
industry (those who work directly for the health insurance company, those
involved in billing health insurance, those involved in tracking per patient
costs, almost all Medicare employees, all those whose work is tied to
administering Medicaid, etc.). Nobody would need to determine an individual’s
eligibility for care as everyone would be eligible. Medicare for all is
estimated to reduce health care costs by 25% or more simply by cutting
administrative costs. In implementing Medicare for all, the government should compassionately
assist those harmed economically by the transition: displaced health care administrative
personnel, health care workers, not just doctors, saddled with outsized student
loans, etc.
Third, health care costs would fall. People would get less
care, because preventive care is less costly than treatment and people who have
free access tend to seek preventive care. Emergency room usage would sharply
decline, as people substituted lower cost options for emergency room care,
which is the highest cost source of care. Personal costs, often less tangible
but nonetheless real, would diminish because people would not need to track
health care costs, make copayments, etc. If Medicare for all paid for outcomes,
not procedures, wasteful tests and procedures would go away.
Fourth, federal funding for health care could rely on a
simple formula of $xx/person served with a higher rate of reimbursement in
rural and other areas in which it is hard to get providers to locate. By
pushing the funding down to states, and then allowing states to fund municipalities,
the federal government could rely on local expertise and knowledge rather than
attempting to decide how to allocate funding among local provider, i.e., rely
upon our federal system to allocate health care funding recognizing that
allocations may vary substantially from one part of the country to the next.
Federal health care administrative costs would be reduced to fifty (or fifty-five,
if one includes the District of Columbia and U.S. territories) monthly electronic
transfers using the modified per capita formula outlined above. States might
choose to utilize current state health department personnel involved in
Medicaid funding to allocate the monthly check from the federal government, keeping
costs to a minimum and allowing municipalities (city, town, or county) maximum
leeway in spending the money or might adopt a more centralized form of control.
That would be a state, not a federal decision. Federal enforcement of
constitutional guarantees of equal rights would still apply, as it does in
other fields, without needing a large, special bureaucracy.
Fifth, as implementation progresses, the federal government
could also give the VA medical system to the state in which the VA facility is
located, allowing the state the option of operating the facility, giving the
facility to a municipality, or closing the facility. Veterans would no longer require
special access to care because all Americans would have equal access to care.
The very simplicity of this proposal has two major strikes
against it. First, special interests – insurance lobbies, groups focused on a
special disease, health care companies – would inevitably strive at every
opportunity to establish preferential treatment for themselves (just think of
the U.S. tax code!).
Second, the U.S. has sadly become less of a federal system and
increasingly centralized. Changing laws or rules at the federal level is easier
than making those same changes in each state and territory. This negates one
huge benefit of a federal system: the opportunity for states to adopt different
approaches, policies, and programs, as a testing mechanism to find what works best.
When one approach, policy, or program is widely perceived as the best, other
states are generally quick to adopt it. People dissatisfied with the approach
to health care delivery in one municipality or state could relocate, just as
they currently do with respect to schools, employment opportunities, etc.
Even if you reject this proposal, not moving ahead with
health care for all because of the difficulty in transitioning from the current
mélange than harms so many and works well for only the privileged few is
illogical and immoral. Health care for all is a fundamental corollary of the
right to life.
