Wednesday, March 20, 2019

Medicare for all


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.

1 comment:

George Clifford said...

An Ethical Musings reader sent me this comment with its excellent insights:

Whenever my colleagues in Europe asked me about the lower life expectancy in the U.S., I explained that if one removes the U.S. African-American and Latino populations from the calculation, life expectancy in the U.S. is essentially the same as in western Europe. The healthcare situation in the U.S. today is closely bound to racism and, previously, slavery. Well-intentioned Medicaid alone hasn't been particularly successful at bringing the health of African-Americans and Latinos to the level that Americans of European heritage generally enjoy. In some states, political questions such as adequately funding Medicaid and expanding participation in Medicare encounter quiet opposition that really has nothing to do with fears of socialized medicine, higher taxes, etc.