I’m just going to come out and say it. I believe that the concept of “Medicare for All” is populist rhetoric aimed at engaging the very progressive and left leaning base. In the next several paragraphs I will try to explain (my opinion) why this type of populism takes us further from securing the health and wellbeing of America.
Populism is a political movement that claims to represent the “will of the people”. Populism is on the rise globally and it is not isolated to either end of the political spectrum but lives on both extremes speaking for those who feel disenfranchised from the mainstream. The United States has a long history of populism. One interesting example of populism that is applicable to our current discussion is the rise of the “Tea Party” movement. The Tea Party rose up following the election of Barack Obama around 2009 at least in part as a reaction to the Affordable Care Act. Although there is not a unified political platform, politicians who arose out of the Tea Party movement in general opposed universal healthcare, supported lower taxes, smaller government, and increased fiscal responsibility. The success of this movement came from grassroots support at the local level with an underlying distrust of the Obama Administration.
The support for “Medicare for All” has a similar feel to the Tea Party movement albeit on the other side of the political spectrum. It seems like a reaction to the current administration’s efforts to undermine the Affordable Care Act. Just like the Tea Party shifted the Republican Party more to the right, the progressive movement advocating for environmental and economic justice is shifting the Democratic Party further to the left. Like the populism of our history, there are good elements to the arguments. Prior populist movements responded to inequity and unfair advantage held by certain groups over others (such as supporting anti-trust movements or women’s right to vote) and our current circumstances reflect an even greater inequality in this country that translates into decreased opportunity for many based on socioeconomic status. The progressive element of the Democratic party and the wave of newly elected officials to Congress, State, and local government are unmasking the illusion of meritocracy in this country that we need to grapple with if we want all Americans to have an opportunity to succeed and contribute in our nation.
But also like the other populist movements, there is a negative aspect to the rhetoric. The current discussion of “Medicare for All” is less about race or national identity and more about an economic divide that casts those who are financially successful as morally inferior. There seems little distinction between those who obtained their wealth by inheritance and those who are achieving success through hard work and innovation. As a doctor, this concerns me. First, I was not born to wealthy people and while I was lucky that my family emphasized education, I obtained loans for college and medical school which I continue to pay many years after completing my education. While I am well off and can provide for my family, I do this through working long hours having sacrificed at least a decade of my life as a low paid resident and fellow working even longer hours than I do now. Like many of my friends, I have pursued academic medicine which has allowed me to care for complex patients best served by the resources and skill of my institution, educate our future doctors who will care for people in the community, and contribute to the advancement of medical science through innovation. While I make less than my colleagues who chose non-academic careers, my life is rich and each of my days brings me new challenges. Progressives will argue that I have benefited from the labor of others that have contributed to my success and I won’t argue that. But does my hard work and success make me the bad person?
This is the fundamental problem with a policy like “Medicare for All”. It is not really being put out there as a reasonable solution but as a tool to divide and polarize people politically. I don’t think anyone would argue that people are entitled to health and wellbeing as a right. But I disagree that healthcare as we currently define the services provided under Medicare is a universal right. In my experience, medical issues tend to break down into two categories. The first are medical issues that occur for the most part out of no fault of our own. We can quibble on the details but many childhood illnesses fit this bill as well as diseases in any age group that have no apparent etiology or caused by infection. Similarly, people injured by crime, accidents, or other circumstances in general did not bring medical misfortune upon themselves. The other large category is disease that we bring on ourselves. This occurs by choices we make in diet, exercise, drug/tobacco/alcohol consumption that lead to changes in our body systems and organs that result in disease. If we provide universal healthcare coverage to everyone, we are saying that people are not accountable for the choices that they make that affect their health and wellbeing. This means that a person who does make good choices in terms of diet, exercise, sleep, alcohol consumption, tobacco or other drug use bears the same cost as someone who chose not to care for themselves.
Defining how an individual should behave and how that influences their medical coverage is not a government decision. We as individuals in a free society should have the ability to make choices that may not be in the interest of our health and wellbeing. However, we as taxpayers should not necessarily have to bear the cost of others’ bad decisions. That being said, even when we think people are making individual choices, there are outside influences that impact their health and wellbeing. Issues of clean water, access to healthy/fresh food, clean air, safe housing and neighborhoods, parks and public spaces to recreate in, and availability of preventative services (vaccines, screening) have a much greater impact on the health and wellbeing of a population than any doctor or “Medicare for All”. It is hard for anyone to argue that we, the people, do not have a right to these basic resources and it seems like these issues are within the purview of local, state, and national government to secure these through allocation of our taxes, zoning, and other policy.
But let’s play devil’s advocate for a moment. Let’s say that we could somehow get our politically divided nation to agree to universal healthcare and a single payer system such as “Medicare for All”. Let’s assume that everyone would agree to raising enough taxes to fund the enormous cost of providing universal healthcare. Do we really believe that a single centralized payer is the best way to allocate resources? Are we confident that resources will be distributed equitably and efficiently and that will translate into improved health and wellbeing of all Americans? Supporters of universal coverage point to most other developed nations as the rationale for this policy. But the truth is that very few countries actually have a centralized single payer. I’m no expert on this but in my brief review, the solutions for universal coverage range from a single payer to employer mandated coverage (Switzerland) to local collection and allocation of taxes to support healthcare (Denmark). While Medicare is a single payer for our population over 65 years old ( and other select populations), it is accompanied by multiple third parties that provide supplemental insurance, prior authorization, review of reimbursement for hospitals and physicians, compliance oversight, funding for graduate medical education, and a myriad of other factors that make this a bureaucratic monolith. Adding everyone on to this program is not a simple matter of expanding the existing infrastructure but would exponentially increase the complexity of an already complicated and inefficient structure.
The last argument I want to make relates to my role as a doctor. We as doctors have benefited from Medicare and support of medical science by the federal government. Despite the fears of the Affordable Care Act, we as doctors and other healthcare providers have had the ability to care for patients that previously would not have had access to care either through the insurance exchanges or expansion of Medicaid at the individual state level. Of course, this has not been a free lunch for physicians or Health Systems as I discussed in my last blog. It has been accompanied by a tremendous increase in regulatory and clinical oversight, barriers to delivering care through prior authorization, narrow networks, and payment structures based on hitting metrics or adhering to guidelines. This is a messy time to be in healthcare delivery but the one upside is that it has got everyone thinking about how our fragmented system can best deliver value-based care. The efforts of all stakeholders as they attempt to grapple with the new world order are actually real time experiments that we can study to understand what is and is not working well in health care delivery.
I am concerned that if we moved to a single payer model, that we would lose this innovation in two ways. First, there is no impetus for a single payer to run any experiment. They can set the reimbursement for a service that encourages certain services being provided and discourages others. As such, the incentive for those who deliver healthcare to innovate goes away. Sure, there will be an effort at reducing costs for health systems to maintain their margin but this is only one aspect of innovation in healthcare delivery and ignores the advancement in medical science that takes place at a rapid pace. Medicare does have the CMMI, ACO, and other programs but I would argue that they do this because of their role in helping direct care for other payers or cost reduction and in the absence of other players in the market, that role would go away.
Second, a system that is designed to deliver health care services to all will naturally need to constrain choice, choose what to cover, and ultimately ration healthcare to contain costs (especially when we do not address the root cause of our health problems). Naturally, with less financial and innovative opportunity, talented people will choose to invest their efforts elsewhere. People who would have pursued a career as a doctor, physician assistant, nurse practitioner, nurse, pharmacist, or other healthcare professional might choose to invest their efforts elsewhere. We already have a shortage of clinicians in our country especially in rural areas and this could exacerbate this crisis. In addition, people and companies that are interested in scientific innovation might look for other opportunities rather than developing the next drug or device to improve care. This won’t happen immediately but will erode what we value about our flawed system over the long term.
There are, of course, many more arguments that can be made against universal healthcare and a single payer and there have been much more expert articles written on this topic than mine. My point is that if we want to do something meaningful regarding the health and wellbeing of our fellow Americans, we need to stop kicking around healthcare like a populist football. Whether it is the left advocating for universal coverage that is too costly and not supported by many who are happy with their coverage or the right who want to tear down any government supported safety net, the arguments being made are talking points and not real solutions. I don’t have an easy solution but I do have thoughts that I want to summarize. I believe our government’s best efforts are placed not in being the sole payer of healthcare (through our tax dollars) but by finding solutions that address the social determinants that negatively impact health especially for those who are most vulnerable in our society. These issues impact everyone regardless of political identity. Second, while the Affordable Care Act is flawed, it has encouraged stakeholders to innovate in how we care for populations. This is also true for Medicaid expansion where states like Michigan have demonstrated real outcomes benefits for their programs. Shifting the discussion from the federal government to the state and local level could allow for solutions that meet the unique needs of local populations by people who are more directly accountable to their constituents. I would argue that we need to “double down” on aspects of our healthcare delivery that encourage innovation both to improve the value of the care we currently deliver and identify better ways to work together to deliver it for the future.
I know my argument is flawed so please share your feelings with me and those reading this. I hope I can stimulate a meaningful discussion on how to deliver better health for all of us and not people sticking to political talking points. Thank you.