Medicare for All?
Over the last few years, I’ve been asked by several of my clients what I think about “Medicare for All.”
Medicare for All is the health-care bill proposed by Bernie Sanders in his 2020 presidential campaign.
Since I try to not talk about politics, I’ve been avoiding the subject since the last election.
However, it doesn’t look like this topic isn't going to go away anytime soon, so I thought I’d outline what the experts—as well as regular folks—determine to be the pros and cons of the subject. I’d love to spark good conversation.
But before we start looking at the pros and cons of the proposal.
I thought I’d give you a bit of the background on it. Sanders's plan includes a freedom-of-choice provision stipulating that people can choose any health-care provider. In regard to this part of the plan, Sanders has said, “You’ll go to any doctor that you want, you’ll go to any hospital that you want.” 1
When I asked listeners of the Rock Your Retirement Show what they thought about the project, Randy Goode of Over50FitnessRx replied:
. . . would like to see Medicare taken down to 55 to see impact on government, health-care providers, insurance cost. Then take it from there. Some common sense recommendations: pay a bit more if you’re 55–64. Also pay more if you smoke tobacco, drink more than 15 alcoholic drinks a week, or are morbidly obese.2
As an insurance agent, I would expect that demand for health-care services would probably go up if Medicare For All was implemented because there would be no co-pays. Where I now live in South Carolina (I moved from San Diego in January 2019), there is a shortage of doctors. It takes about three months, I’m told, to get in to see a primary care physician. I’m imagining the length of the wait if co-pays were zero!
For that very reason, I signed up for direct primary care (DPC) physician myself. She doesn’t accept any insurance but charges her patients what I call a membership fee. Her patients get her home phone number and can call to see her anytime they are sick.
And I’m not the only insurance agent who has weighed in on the subject.
Troy Baccus of Medicare Life Group is opposed to the expansion of Medicare until the specifics are known.
Right now there is just too much up in the air about how the new program will be run.
Ultimately, whether “Medicare for All” ends up being simply an expansion of the current Medicare system to all ages or an entire revamping of the system isn’t known. Therefore, at this time we oppose a blanket expansion of Medicare until specific details are laid out.
Expansion of the already massive Medicare program will certainly become entangled in a political debate that prevents a smooth and quick implementation.
One thing that many folks who aren’t already on Medicare might not realize is that expanding the current version of Medicare to all ages doesn’t eliminate the need for private insurance. The vast majority of people enrolled in Medicare also have a supplemental plan since Medicare itself only pays for 80% of medical bills, plus other deductibles.
Additionally, there may be a misconception that Medicare is free. Currently, most people enrolled in Medicare pay a $135 premium per month, with those in higher income brackets paying more.
One thing is for certain, if a “Medicare for All” bill passes, it will come with growing pains, but hopefully it’s designed in such a way that it can be modified and improved over time to work out the kinks. We can only hope that our elected officials take on the responsibility of fixing America’s healthcare system rather than politicize the issue in decisive 10 second soundbites for Facebook.3
Just because someone is an insurance agent—and may lose his or her job if the bill passes—doesn’t mean that he or she is opposed to any form of it.
Kumar Goel of Lighted Road Insurance believes in a public-private partnership (kind of like Medicare Advantage).
Of course, Medicare Advantage plans do not cut out the insurance broker . . . but Sanders’s plan does!
Goel explains his view as the following:
How can healthcare for all be a bad idea? It is an excellent idea for sure. And it will need active support from the government; otherwise many sections of society will be left behind.
There is no country in the world where this has been done without an active role played by the government—be it laws, regulatory framework, policies, taxes, incentives for healthcare providers and facilities or something else.
Given the US legacy of privatized healthcare, it may be better to implement a public-private partnership model. Current Medicare does the same. In a nation where most medical professionals are employed by the private sector, most healthcare facilities are private and most health insurance is private, it would make a lot more sense to enhance the current Medicare model instead of the government trying to take over everything related to healthcare.
We can create an outline of a National Health Service by merging ACA and Medicaid with Medicare. These are existing programs and their financial and societal impact is well understood. This will help create a national framework for providing healthcare services to all.
There is no need to transition to “government as the single-payor” model on Day One. Because frankly, that day may never arrive in the US.4
Ted Chan, CEO of CareDash, a website that reviews doctors, agrees with Goel.
He believes in a Medicare Advantage–type Medicare for All program.
First and foremost, we should have Americans insured in some way. Before Obamacare the uninsured went into hospitals or had emergencies just the same and couldn’t usually pay. People went broke and/or hospitals absorbed the cost. With insurance, hospitals are paid for these services and could budget and staff appropriately. These costs will get passed back to consumers and companies. Having people uninsured is suboptimal from an economic perspective and a drag on the US economy.
The problem is fee-for-service Medicare is not an efficient way to deliver care to the broader American citizens. I see much more potential in a Medicare Advantage structure where a capitated amount is paid into care networks who are responsible for providing quality care to their patients. This brings in key principles of value-based care, including cost and risk management into the equation and encourages innovation in the quality of care. In this paradigm, the government plays more of a role setting high standards for quality of care, and value delivered while protecting the patient.
This wouldn’t preclude some models that I see as effective such as Direct Primary Care where a physician or practice is paid directly by the responsible party (individual, employer, state, or federal) but is the effective insurer taking on the benefits.
It will be complex to figure out who will be responsible for payment for the different pools who need to be paid, including those currently corporate insured, Medicaid, uninsured. That said, it’s worth it to get everyone covered with a competitive plan.5
Of course, just because one is part of an insurance or medical-related industry doesn’t mean that he or she is for or against Medicare for All. I personally understand the need for this plan, but I’m not sure if I am “for” or “against” Medicare for All. I’m waiting to see what the final bills will say. I’m waiting for experts who know more about the problem and possible solutions than I do.
And speaking of experts . . .
I also heard from a health-care policy expert. This heavy hitter is a member of the Executive Council of the Harvard School of Public Health, with decades of experience in the industry as a former top-level partner with Booz Allen Hamilton and Accenture and as a health-care IT entrepreneur, board member, start-up advisor, and author of Untangling the USA.
This policy expert is definitely “for” a change. Here’s what Etienne Deffarges had to say:
Offering Medicare for All is a moral imperative, and it will also reduce U.S. healthcare costs.
We need to offer every American a Medicare option, to achieve universal health care in our country. This is not only a moral imperative, but an economic one as well, for three reasons:
1) The U.S. has by far the most expensive healthcare system of any high-income nation:
We spent $3.5 trillion in this area, or 17.9% of GDP. Americans spent $10,740 on health care in 2017, more than twice as much as of our direct economic competitors. This per capita healthcare spending was $5,700 in Germany; $5,000 in Australia; $4,900 in France; $4,800 in Canada; $4,700 in Japan; $4,200 in the U.K.; and an average of $5,300 for a dozen such wealthy countries, according to the Kaiser Family Foundation and OECD data. Spending almost a fifth of our GDP on healthcare, compared to 9–11% for other large developed economies (and much less in China), is like having a chain tied to our ankles when it comes to our economic competitiveness.
2) Health outcomes in our country are below par relative to other developed economies:
In many annual health studies, ranging from the World Health Organization (WHO) indicators to the Bloomberg health efficiency index, the U.S. lags most other developed countries in life expectancy; infant mortality; women’s deaths in childbirth; heart disease, and several other health outcomes. For example, according to WHO rankings for OECD countries, U.S. life expectancy at birth was 79 years in 2017, versus 84 years in Japan; 83 in Australia and France; 82 in Canada; 81 in Germany and the U.K.; and an average of 82 years in Europe and Japan.
3) We still have 30 million uninsured people in the U.S., whereas every other developed country enjoys universal healthcare: This is a very undesirable type of “exceptionalism.”
In a nutshell, the only healthcare system we cannot afford is the one we have today. Bringing universal healthcare to all Americans will not only correct one of the worst injustices of the modern world, and put an end to a national embarrassment, but will also help contain our healthcare costs, and prevent them from growing to be an unaffordable share of our GDP.
How to offer Medicare for All? The most straightforward path to this solution is to build upon what we already have and works well today, to avoid a complex, messy and expensive transition to a new model of universal health care in the U.S.
Today, Medicare and Medicare Advantage plans are extremely popular, with the government providing the safety net and the private sector being very involved in more comprehensive plans. Why not extend this to all our population, with more economical plans for the young? This is the simplest way to achieve universal coverage, with both a public option that would offer Medicare to anyone wanting it and private plans—people who are happy with their work-related private insurance could keep it. It is important to keep the ability of the private sector to innovate in the area of leading-edge medical treatments, and provide enough capacity so that no queuing exist, even for medical operations that merely improve our physical comfort. We need to do this with particular attention on the overall costs of the system, to prevent our healthcare costs to crash the barrier of 20% of our GDP, something that could well happen within a decade if current trends continue. How would such a solution work?
- Medicare would be extended as government-guaranteed health insurance to everyone above 26 years of age who would want it, younger individuals keeping the option to stay on their parents’ insurance plans, as they have today.
- As a cost containment measure, today’s Medicare, which is a very generous and comprehensive plan, would remain available only to those sixty-five years of age and older. It would be called “Comprehensive,” or “Platinum.”
- There would be three, lower cost but higher co-pay and deductible plans. A “Basic” Medicare, akin to a “Bronze” plan, available to those between twenty-six and forty, with the lowest fees but highest co-pays and deductibles; a “Silver” plan, available to those between forty and fifty-five. And a “Gold” plan, available to those between fifty-five and sixty-five. The health exchanges set up as part of the ACA would be closed.
- Anyone wishing to get better quality coverage than provided in the Basic, Silver, Gold or Comprehensive Medicare plans, would have to go to the private sector for supplementary coverage providing lower co-pays and deductibles. All such private sector supplementary insurance plans, as well as remaining employer-based coverage, would be allowed to operate across state lines. Private health insurers would be encouraged to compete nationally, just like any other form of insurance such as for homes or cars. The tax deductibility of employer-based coverage would be ended, saving the U.S. Treasury at least $250 billion per year.
A number of obvious improvements could also take place in this new healthcare regime, starting with allowing the new, expanded Medicare to negotiate drug prices directly with pharmaceutical companies. The imports of prescription drugs from other reputable developed countries would also be freed, bringing welcome competition in this area, and ending an era of widespread drug pricing abuses in this country.
Beyond a relatively short transition period, this Medicare for All system would reduce costs in our healthcare system in a number of ways:
Reducing system complexity would reduce costs: Our current healthcare system in the U.S. is a massively complex construction, involving a lot of entities: government ones, e.g., Medicare; 50 Medicaid programs; the VA, etc. In our country, 62 cents out of every healthcare dollar in our country is spent by government entities: in that respect Uncle Sam is much more involved in our healthcare system than, say, the governments of Germany, the Netherlands or Switzerland; private sector ones, some not-for-profit (e.g., most U.S. hospitals; the Blue Cross Blue Shield insurers; the Kaiser Health Plans) and others for-profit (e.g., giant insurers like United Health and Aetna). This creates myriad interfaces that make the system both unproductive and ineffective.
In the above proposed Medicare for All system, there would be a strong reduction in healthcare-system complexity, and the overlapping role of the private and public sectors. A government more focused on our health, and a private sector free of playing a role in our welfare, would both become more effective as a result. The system described above would be a lot simpler than today’s healthcare in our country. The administrative costs of the existing multi-state private-insurance plans within each state (remember, our current private system of private insurance does not cross state lines) would be greatly simplified with one national, Universal Medicare Option plan. Private Medicare supplemental plans would operate across state lines, transforming a multi-state system into a national one, also simplifying administrative processes significantly. The fifty state Medicaid programs, with their enormous differences, would essentially disappear. States that would elect to administrate Medicare in their state would do so under a unified set of national guidelines. The mosaic of interactions between the governments—federal and fifty states—and the private health sector today would be replaced by a much smaller number of interactions between Medicare and private plans operating at a national level. The ACA’s health exchanges at the federal and state level, a source of much complexity and poor results, would cease to exist. With them a whole lot of very complicated and confusing set of eligibility rules, subsidies and tax credits would disappear. The roles of the federal government and the private sector in healthcare would no longer overlap significantly like today. The government would focus on universal healthcare with basic coverage, the operations of VA hospitals, some medical research and the regulatory role played by the FDA. The private sector would do all the rest, including operating most of our hospitals. With this simplification of state-private interactions in healthcare, information systems could also become much simpler over time.
Healthcare administrative costs could finally go down: Out of control healthcare administrative costs have risen a whopping 65% over the last decade, and totaled $260 billion in 2017. What good can come out of excess administrative costs? Employment! Yes, but this is not the type of employment that adds to our economic competitiveness. . . . We spend more on administrative costs than the United Kingdom, a country of close to 70 million people, spends on total healthcare. Let’s do some quick math here: The half dozen large developed economies mentioned above spend an average of 2% of total healthcare costs on administration, versus 7.4% in the U.S. All other things being equal, if we too spent 2% on administrative costs, we would save $190 billion per year, enough to insure pretty much all our uninsured, even at today’s costs.
In today’s system, unlike in any other industry, technology innovations have led to increases, not decreases in costs, and administrative costs have grown hand in hand with ever more complex electronic health records, patient accounting systems, the use of big data and other IT innovations. Complexity reigns supreme in U.S. healthcare, and even Silicon Valley is unable to do anything about it. This sad state of affairs is the reflection of the enormous complexity of our healthcare system, and as long as we cannot surmise the political will to do a complete overhaul of how we provide healthcare to our citizens, this will continue. This is why moving to a fundamentally simpler system like the one proposed above is the only path to reduce these costs.
Increased competition would lead to significant cost reductions, starting with the cost of drugs: In the land of free markets, competition and open markets are systematically thwarted in healthcare. For example in most states there is at best a duopoly of health insurers, with little or no competition. But the best illustration of this is pharmaceuticals. Drug costs have grown in double digits annually in the ’90s and 2000s, reaching $333 billion in 2017, or almost 10% of our total healthcare spending. As a result, Americans spend about twice as much in this area than residents of other rich developed countries. For example, the cost of a vial of Humalog insulin made by the U.S. company Eli Lilly is $55 in Germany, versus $137 for a generic brand and $275 for the Humalog branded one in the U.S. As is often the case in industries with “cosy” government relationships, we also have seen far too many scandals in the U.S. pharmaceuticals industry: Remember Martin Shkreli? The Valeant Saga, which made many people comment that drug companies should not be run like hedge funds, or Enron? And so many prices abuses, even by reputable companies like Gilead?
Why is the price of drugs galloping in the U.S.? For two simple, anti-competitive reasons: First, the absurd clause in Medicare Part D that prohibits Medicare/CMS to negotiate drug prices directly with pharmaceutical companies. Have you ever heard of any other large industry where the principal purchaser of products is not allowed to exercise its negotiating power? I think not. Second, the fact that we prohibit drug imports from reputable developed countries (think European Union countries; Japan; and Canada) to enter our country to increase competition in this very large market. This corporate welfare for drug companies needs to end, yesterday.
Under the proposed Medicare for All healthcare system, we would stop protecting our pharmaceutical companies by freeing their largest purchaser, Medicare, to negotiate with them, and allowing lower-cost imports from reputable countries. With increased competition, and a genuine free market environment, drug costs would follow what happens in any competitive industry, and go down significantly.
A Medicare for All system would encourage providers to move to value-based pricing: Most services provided by U.S. physicians are under a fee-for-service regime that encourages overtreatment. In contrast, there are emerging “capitated” (i.e., with a not to exceed ceiling) reimbursement models revolving around the primary care physician, who acts as the “gate keeper” to other care givers such as specialist physicians. In these models, for example applied to senior populations, Medicare pays a fixed amount per “life insured” to Medicare Advantage plans who then work with independent physician organizations managing patient populations. These coordinated care models, where doctors are empowered with data, technology and nursing teams, produce the best patient satisfaction and cost efficiency, managing global risk for commercial, Medicare Advantage and dual eligible populations.
In summary, our current healthcare system is not sustainable. Almost nobody in the U.S. understands why insuring one’s family has to be so complex and expensive. Incremental changes to our system only add to its complexity, and its costs. At the same time, 30 million Americans do not enjoy access to healthcare coverage, with another 30 million suffering from sub-par insurance plans. This is both a moral stain in our nation and an economic catastrophe. It is time for comprehensive change. Medicare for All will both address the healthcare moral imperative we face and provide our economy with a welcome relief on the current system’s costs.6
David Belk is an MD, and he is also “for” making a change to the system.
In fact, he has an entire website devoted to it. Following is an excerpt of his view:
If the U.S. were to have a Medicare for All healthcare system there would be several advantages over our current system. The problem would be in getting from here to there. I’ll summarize both the advantages and the obstacles:
- Cost—Medicare is less expensive than private health insurance for several reasons. The main reason for this, though, is that private insurance companies tend to pay hospitals far more for medical services than either Medicare or Medicaid will.
Figures 9–15 in the above link show that private insurance companies, on average, will pay about twice as much for either a hospitalized patient or an outpatient service than Medicare or Medicaid will pay. As a result (Figure 15 above) hospital costs per enrollee have been nearly flat for Medicare recipients since 2009 whereas these costs have risen by around 60% for the privately insured in that same time.
- Simplicity—Medicare pays a set rate to all providers within a region for each approved medical service. No provider would need to guess what they’ll be paid in a single payer system.
- Transparency—Medicare posts all fee schedules online, again taking the guesswork out of costs: https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx
- Congress—Passing a bill that expands Medicare has been tried many times in the past, and has failed each time. Republicans will oppose the measure at all costs and some Democrats will invariably join them.
Hospitals—Hospitals would likely lose tens of billions of dollars a year in a single payer system when compared to what they make now. They’ll oppose the measure at any cost.
Health insurance companies—They’re huge right now, and very powerful.
They also control much of our healthcare system. They can say just about anything they want, and far too many people will believe them without question. Whatever terrifying message they wish to broadcast about the horrors of a single payer system would repeated reliably and endlessly by our media. see: https://www.huffpost.com/entry/did-united-health-really_b_10798584
That alone would be enough to kill just about any meaningful reform proposed to improve our healthcare system (unfortunately).7
But I’m still not convinced about Medicare for All. For example, although Sanders talks about being able to see any doctor, I find it unlikely due to my previously mentioned experience in South Carolina. According to FactCheck.org, demand will likely increase and consumers would likely be faced with longer wait times.
But with universal coverage and zero copays, demand for health care services would likely increase. “[T]he Sanders plan would increase demand for health services by eliminating individuals’ direct contributions to care (i.e., by eliminating deductibles, copayments, and coinsurance), but not all increased demand could be met because provider capacity would be insufficient,” the Urban Institute said in a 2016 analysis of Medicare for All, which was similar to the current bill. The Urban Institute incorporated “provider supply constraints” in its estimates. Similarly, a RAND analysis published this year said that “providers’ willingness and ability to provide health care services—including the additional care required by the newly insured and those benefiting from lower cost sharing—would most likely be limited.” The extent of this issue would depend on the change in individual providers’ payments and their responses. RAND said: “As a result, some patients might experience longer wait times for care or face unmet needs.”8
According to Sanders, we could still enter into private contracts with health-care providers (like the contract I have with my DPC provider). If the bill passes, I would have to pay the taxes needed to finance the plan on top of the monthly fee that I pay my DPC doctor.
But the DPC monthly membership fee isn’t all I pay. In San Diego, I paid over $500 per month for a high-deductible plan. Here in South Carolina, I’m paying about $300 per month for a Health Sharing account (this is not insurance). I wonder, would my taxes be more or less than what I now pay for my Health Sharing account or what most people pay for insurance?
Or would it put such a burden on the economy that we would be hurled into our next depression? Fact Check goes on to say,
The new “universal Medicare program,” as the bill calls it would cover: hospital inpatient and outpatient services, ambulatory services, primary and preventive care, prescription drugs and medical devices, mental health and substance abuse treatment, lab and diagnostic services, reproductive and maternity, newborn care and pediatrics, dental/hearing/vision services, short-term rehab, emergency care, transportation for low-income and disabled individuals to receive these services, and home and community-based long-term care. The bill would eliminate the Hyde amendment, which now restricts federal funding of abortion to only cases of rape, incest or endangerment to the mother’s life. The secretary of the Department of Health and Human Services could change or expand the benefits.
Current Medicare benefits would be expanded, since they don’t include dental, hearing or vision coverage now. Also, Sanders’ bill calls for virtually no out-of-pocket costs at the point of service for these benefits. There would be no copays, deductibles or premiums, with the exception of prescription drugs and biologics (such as vaccines and gene therapy), which could carry copays totaling no more than $200 a year per person, indexed for inflation.9
Fritz Gilbert, author of The Retirement Manifesto blog, thinks it sounds good, but he warns about the national debt that would likely increase:
While Medicare for All sounds like a wonderful gift, especially as a young retiree, we’d be naive to think that anything comes without a cost. I worry about our nation’s ability to handle the price of the programs we’ve already committed, and think Medicare for All would be viewed as a mistake in the long term due to the negative impact on our national debt burden.11
Sanders thinks that our overall payments for medical expenses will decrease. According to Bernie Sanders, a family of four pays $28,000 per year for insurance. But a Washington Post video called “Fact Checker”10indicated that this figure comes from the 2018 Milliman Medical Index, which is used for insurance that people get through an employer, not for those who are self-employed.
The video indicated that almost $16,000 of that $28,000 is already covered by employers. This means that the average family of four pays a little over $12,000 per year for their insurance now, not the $28,000 that Sanders claims. So the question is whether the average family of four will see an increase of more or less than $12,000 per year.
The Washington Post video goes on to say that our final costs will depend on four factors.
Those four factors are as follows:
- Payments to Providers
- Benefits Package
- Cost Sharing
- Administrative Costs
If we reduce payments to doctors, hospitals, and other providers, then we may have some savings in that area. Is it reasonable to assume that we can reduce payments to doctors and hospitals?
The video did bring up long-term care costs, which are currently being excluded by the proposal. Since long-term care costs are currently excluded from the Medicare system, excluding them from Medicare for All seems fair to me.
Paige Cunningham of the Washington Post video also stated that employees “will often face a deductible as much as $5,000 [to] $10,000” and that Sanders’s plan would eliminate all of this and that people would be able to go to the doctor without any extra cost.
Opponents think that being able to see a doctor at no extra cost will lead to overuse and overburdening of the system.
Glenn Kessler, a Washington Post fact-checker in the video, also stated that if “they” aren’t able to get the efficiencies we are promised, “healthcare’s gonna cost more.”
He goes on to say that the two largest past government programs, Medicare and Medicaid, had unintended consequences. Can we count on being able to save money on the new Medicare for All plan? According to the Washington Post video, only under the most favorable circumstances would this come to fruition.
Another insurance agent, John Holloway of NoExam.com, believes that it is a good idea, but with limitations.
My opinion on Medicare for all is that it is a good idea overall, but care must be taken to avoid widespread financial problems if it passes. I spent the early part of my entrepreneurial career being uninsured, and nothing draws more looks of bewilderment than telling a provider you are self pay.
As a business owner and insurance broker, I worry about the ripple effect through the industry as a whole if it passes. Insurance companies will lose revenue, but they will make up for it elsewhere. They always do. This will come in the form of higher prices for other products, lower commissions for agents, and other cost-cutting measures. If it passes, there will be nothing I can do except to roll with the punches.
If providers are suddenly being paid 50% less than they were with private insurance, many providers will go out of business while others struggle to adapt to the new system. This could lead to a lot of lost jobs. I worry that our hospitals could start looking like shopping malls. Abandoned.
Overall I think it is a good idea. Not having insurance is a nightmare. I just hope a plan that was rushed and not well thought out does not get passed.12
Ted Carr, the host of the RetireHoppy podcast, agrees with Randy Goode on getting a “Medicare at 55” proposal on
Ultimately I’d like to see Medicare replace the ACA. But that’s not feasible in today’s divisive and politically contentious culture. Instead, I favor an incremental approach—Medicare at 55. This allows time to monitor, assess and make improvements with less risk.13
However, Carr realizes that this can also be a challenging proposal. Carr sees the following challenges to his goal of Medicare at 55:
- People and politicians opposed in principle for various reasons.
- Should buy-in to Medicare at 55 be optional or mandatory?
- Should Medicare at 55 be available to people who receive employer-provided health insurance?
- Should Medicare Advantage and Medigap plans be available?
- How will hospitals be affected due to receiving lower Medicare payments?
- Should Medicare at 55 offer subsidies like the ACA?
- Is participation permanent or can people opt out?
- How will Medicare at 55 affect Medicare’s projected budget deficit and what are the potential funding options.14
All good points, for sure. Perhaps one of our congresspersons will take a look at Carr’s proposal and create an additional option. Carr continues with the following:
My proposal for Medicare at 55 is driven by two overarching beliefs: 1) failure, i.e., acceptance of the status quo, is not an option; and 2) I view health care as a right and not a privilege. Why not Medicare at 55 to bail out the ACA? I haven’t come across a better solution.15
Before I started writing this article, I hadn’t seen a lot of buzz about Medicare at 55. If it goes through, it will help me personally because I’m nearing that age, and I’d love to hear more about how a plan like this would work.
President Clinton brought up Medicare at 55 during his tenure, and the idea fell flat.
But Medicare at 55 has its proponents. Richard Vague of The Hill writes the following:
Medicare at 55 is important, timely, and politically feasible, which means it can deliver significant relief soon. This highlights one of the real problems with “Medicare for all,” which has recently been trumpeted by so many 2020 presidential contenders. It’s simply not something we can get done in any near-term timeframe, and Americans need help now.16
He also thinks that it has a chance at passing.
It is politically feasible because it helps the average family and because hospitals and insurers will still have their roles: A 55 year-old employee of a company can stay with her current policy or choose Medicare or Medicare Advantage. It is also feasible because by age 55, most folks have been paying into Medicare for decades. Lastly it is feasible because it is affordable. The employer will still contribute at the same level. Medicare also has cost advantages compared to other insurers since it accounts for 30 percent of U.S. health-care spending and has by far the greatest buying power. It does a better job containing costs, so this advantage will increase over time.17
Vague also believes that Medicare at 55 programs will also save employers money.
Most importantly, for employer-provided plans, Medicare at 55 will take on the highest-cost participants, and businesses will be left with younger and healthier participants and therefore better able to hold premiums and deductibles flat—if not reduce them.18
Senator Debbie Stabenow, one of the original authors of the Medicare at 55 bills in 2017, has a revised bill that would allow people to buy into the Medicare system at age 50.
Stabenow admits that she is a proponent of universal health care, but she also points out that Medicare includes a privatized option called Medicare Advantage.
I certainly embrace the goal of universal health care coverage. To me, it’s a question of how that’s designed. Even with Medicare right now, private insurance participates as Medicare Advantage.19
Many seniors don’t realize that when they enroll in a Medicare Advantage plan, they are enrolling in a privatized Medicare plan. What this means is that they still pay for Medicare Part B, and they still have Part A, but cannot use it the same way that someone who didn't enroll in a Medicare Advantage Plan can. This is because Part C (Medicare Advantage) replaces Parts A and B, and sometimes Part D.
In other words, with original Medicare, you can go to any doctor who accepts Part B; there are no “networks”. If you are having a covered service, there is no “utilization review board” telling you that your service won't be paid for.
Yes, you can file an appeal if your service or claim is denied with MAPD, but with original Medicare you don't have to get permission to, for example, have 14 home health visits. If a qualified professional (such as an MD) says you need 14 visits, original Medicare won't send you notification that they will only cover 4 visits. Limiting your services happens on Medicare Advantage plans, whereas it doesn't happen on original Medicare, for most services. This is one of the biggest issues my clients have with these types of plans.
Even though the rules say that the salesperson must indicate that it’s not a supplement insurance plan, so few people understand the difference between Medicare Advantage plans and Medicare Supplement Insurance that I created a video on the difference between Medicare Advantage and Medicare Supplement Insurance.
Once the bill is fully implemented, it would be “unlawful” for “a private health insurer to sell health insurance coverage that duplicates the benefits” provided under Medicare for All, and employers couldn’t provide such benefits either. However, private insurance could be sold to cover additional benefits that the new universal system didn’t cover—perhaps cosmetic surgery or other non-medically necessary care….20
There would be no Medigap insurance or Medicare Advantage.21
But there might still be insurance, just not for things that are covered by the Act.
It would replace all other insurance, with limited exceptions, such as cosmetic surgery. Employer-provided insurance, Medicaid and ultimately Medicare would all disappear.22
Not surprisingly, insurance companies and some medical groups are against Sanders’s version of Medicare for All.
The health care industry has mobilized against Medicare-for-all because it sees the idea, and even more incremental proposals, as existential threats.23
Stephen Schimpff, MD, a past guest on the Rock Your Retirement show, author of Longevity Decoded, and owner of MedicalMegaTrends.com, believes that it could be used to pay for Direct Primary Care.
If this were to pass, I could use it for my own DPC doctor.
I believe everyone should have the right to basic quality healthcare and it is critical to find ways to reduce or at least slow the escalation of healthcare costs. Medicare for all sounds appealing on both counts but not so fast . . .
Medicare today is driven by a large bureaucracy which limits and stymies innovation from the ground up—by the physicians who know and understand the issues. Medicare is inadvertently a major cause of cost escalation. It also inadvertently reduces rather than enhances care quality.
Currently Medicare pays primary care physicians poorly at best, an approach mimicked by essentially all commercial insurers. Meanwhile Medicare has created innumerable added burdens which drive up office costs and suck physician time away from patient care.
As a result, the primary care physician has found it necessary to “make it up in volume,” seeing 24 to 30 patients per day. This means 10 to 12 minutes of “face time” with the physician. This is enough for the “simple stuff” but not for dealing with complex chronic illnesses. The result is excess referrals to specialists (driving of costs but not quality) when, with adequate time, the primary care physician could have managed the issue(s). Short visits are definitely not adequate for someone with hearing, vision, cognition or mobility deficits and is not long enough to deal with the attendant anxiety that drives about 30 to 40% of visits.
Without adequate time, the primary care physician cannot delve into the psychosocial background of the patient, understand the full spectrum of the patient’s needs and is not enough to develop that deep, empathetic relationship that leads to trust and true healing.
Since Medicare for All will undoubtedly follow the same pathway as Medicare for seniors, I would strongly recommend against it. Only if and when the government bureaucracy finally realizes that their policies have led to a decline in quality, a decline in trust, and concurrently a huge increase in expenditures will Medicare for All be sensible.
Just to be clear, Medicare has served a distinct need since its enactment decades ago and has prevented many seniors from financial ruin. But it has concurrently damaged the patient-physician relationship, driven up the costs of care and burdened the physician with time consuming requirements. That is not good enough.
One suggestion—Medicare could agree to pay the costs of direct primary care. In this model, the physician limits his or her practice to about 500–800 patients and for a reasonable annual (or monthly) flat fee agrees to offer same or next day visits, each visit as long as necessary, access 24/7 via cell phone, an extensive annual evaluation and deep attention to overall health, prevention and true wellness. The primary care cost is real but reasonable; the care is greatly improved; the use of specialists plummets; excess lab tests and imaging and ER visits decline as well. Patients are satisfied, physicians no longer feel burned out. It is a win-win for all. But it can work for Medicare only if it agrees to pay the fee but then butt out.24
Another medical practitioner, Mary Ann Block of BlockCenter.com, voiced her reasons for why she is against it.
She believes that HSAs should be used instead to provide full coverage. Her reasoning is as follows:
12 Reasons You Do NOT Want Medicare for All (Single Payer)
- If you give the government control of all the medical care dollars, they can take the money from health care and use it to give another tax break to the wealthy.
- The government continuously lowers payments to doctors who take Medicare so fewer doctors will be available.
- Doctors who take Medicare have to see many more patients per day to make the same income.
- The 7 minutes a doctor spends with a patient will be shortened even further.
- Pharmaceutical companies will make even more decisions about your medical care.
- More prescriptions will be the solution to every problem because they are easy, fast and cheap (for the doctors and insurance companies).
- Psychiatric prescriptions will be prescribed even more as there is no need to spend money on lab tests if you have a psychiatric problem. Doctors are already being encouraged to make psychiatric diagnoses for this reason.
- There would be even less competition to actually help people.
- There will be no medical innovations or cures.
- Even with Medicare, you must have another insurance policy to receive decent care . . .
- Those who cannot afford a supplemental insurance policy to go with their Medicare will not receive the same quality of medical care as those who can afford it.
- The government is already limiting medical care for the elderly. They do not get approved for many procedures because of age and because they are on Medicare.
Universal Health Care can still be an option but health care dollars should be controlled by the people who use them . . . Us!
Health Savings Accounts (HSAs) are the answer. HSAs are not completely unlike Medicare in that people pay into an account to be used when they need it. The difference is that everyone also pays for a catastrophic policy that covers them in case of a serious illness like cancer or hospitalization. The Health Savings Account allows you to decide what you spend the money on. The government doesn’t decide what you spend it on. Perhaps you would rather spend your health dollars on nutritional supplements than an antibiotic when you have a virus, since antibiotics don’t work for viruses. Maybe you want to choose your own doctor, not one from a list that your insurance company wants you to choose because they are cheaper for the insurance company.
For those who cannot afford to put money into the HSAs themselves, the government helps with the dollars needed to give everyone an equal opportunity to have the best medical care they choose. Money that is now being spent on Medicaid and Medicare can be used for that purpose.
Imagine having such control over your medical dollars that if a doctor doesn’t help you, you can go to someone else and give them your medical dollars. This would start a good competition in medicine. Doctors would have to get you well and keep you well if they want to continue to be paid.
This would even the playing field for everyone. There would be no difference between the care received by someone who has money and someone who does not. Everyone would have the same card to see whichever doctor they wish. Doctors would be paid for the service they render. If the patient is not happy with the care, they can go elsewhere. This will insure that doctors do a better job than they do today. With Medicare for all, unfortunately there is no incentive for a doctor to do better, to fix a problem rather than just prescribe a drug.
At the end of your life, if there are any dollars left in your account, it can be passed to your family to help them with medical expenses. It is your money and should not go to the government if you don’t use it.
Does anyone think it is odd that the insurance company pays your doctor by not how well they do their job, but by how well they “code” your diagnosis and treatment? Shouldn’t they be paid by how well they do their job? Should they be paid if they don’t help you or make you worse?
The reality is that you may think you are getting good medicine from your doctor when you go in, tell the doctor your symptoms and walk out with a prescription but you may not be. Does it ever occur to you that you may not need that prescription? Does it ever occur to you that the prescription may have so many side effects that you could be worse off taking it than you were from the symptoms that led you to the doctor to begin with?
We have all been taught that doctors know everything and we can trust them to get us well and keep us well. The unfortunate facts are that the paradigm of most doctors is “Name It and Drug It.” Give you a diagnosis and a prescription. Medical research today has nothing to do with finding the real underlying cause of a problem. Medical research is used to test another drug for the same condition for which we already have 5 drugs, so the pharmaceutical companies can have a new patent and charge a lot more for their drug than they could for a generic one.
Drug reps (employed by the drug companies to market drugs to doctors) only give samples of the patented, expensive drugs so if your doctor gives you a sample and you continue to use it, it will cost a lot more than a similar drug that can be purchased generic. Drug reps don’t tell doctors about the side effects of the drugs they are pushing. One drug rep told me doctors don’t even ask about the side effects. Even the drug rep was concerned about that. Drug reps have told me they don’t trust doctors because they know they are the ones telling the doctors about the drugs and they are marketing, not teaching.
The FDA has stated that less than 1% of doctors know the side effects of the drugs they prescribe. Now, that should scare everyone. I have found this to be true. For example, a 9-year old girl was prescribed two drugs that were not even indicated for children. She developed complete, total amnesia. When her mother asked the doctor if the drug could have caused the amnesia, the doctor told her, “No, the drugs did not cause it. Increase the dose.” If the doctor had known the side effects of the drug prescribed or at least looked it up when the mother asked, he would have seen that “Amnesia” was listed as a side effect to both drugs. This situation is not rare.
With Medicare for All, this will occur even more as doctors will feel they don’t have time to look up drug side effects. By the way, it takes about 2 minutes to look up side effects of drugs so there is no excuse to not do it.
Single payer or Medicare for all is not the answer. When the government controls all the medical dollars, they will decide who gets what care. If you are over 75 years old, perhaps they will decide that you don’t deserve any more dollars. Maybe they will decide that for 65 year olds. If you have a child with serious medical problems, perhaps they will decide that the child will use up too many medical dollars in its lifetime.
I don’t want the government deciding how I spend my medical dollars or whether I deserve to live or die. Members of the government have too many biases. We all saw that a group of male legislators were making all the decisions on women’s health. There was not a single woman on the panel.
There is an unfortunate attitude that some take, in which they use the medical system even if they don’t really need it, like people going to the emergency room for a small cut on the hand or going to the doctor for a cold. For some, if the service is free, they will use it even if they don’t need it. This just wastes dollars that could be used elsewhere.
I have seen older individuals taking 12 medications. Do they need all those drugs? Not likely. Type II Diabetes is one of the most diagnosed health problems in the elderly. There are many drugs people can take for it but it is 100% curable with diet and exercise. Doctors seem to not give that advise or they don’t spend enough time with the patient to help them with a diet and exercise plan.
Cholesterol is the precursor to all of our hormones. If our hormones go down, cholesterol will go up to make more. A study performed at Yale University found that we actually live longer if our cholesterol is higher. If that’s the case, think of all the money that could be saved if most cholesterol drugs were no longer needed.
There are many instances such as these in which a prescription is not really needed. Some doctors will prescribe an antibiotic for a cold. Antibiotics don’t work for colds because colds are viruses. Doctors have been taught that a patient will leave and find another doctor if they don’t prescribe something. Wonder who taught them that? Could it have been the pharmaceutical companies?
People who want to see Medicare for All, often compare us to other countries, saying we are the only industrial country that doesn’t have Universal Health Care. “It works in those countries so we should have it here.” The United States is not like these other countries. The other countries do not have a legislature that is controlled by the pharmaceutical companies. Other countries encourage the use of so called “alternative” treatments. The Queen of England uses Homeopathy. In the US, the drug companies are trying to ban Homeopathy. As long as drug companies have lobbyists who spend billions of dollars to influence the FDA, the CDC and the politicians, the U.S. will not have a healthy population.
The U.S. medical system is broken. The insurance companies and the drug companies control the dollars. The only way it will improve is to give the control of the dollars to the people. Ultimately it will cost less and we will have a healthier society.25