This piece is part of Fighting for Our Lives: The Movement for Medicare for All, a Truthout original series.
As Republicans come under pressure from the White House to complete the process of repealing and replacing the Affordable Care Act (ACA) so they can move on to other priorities, they are finding that this is one campaign promise that is very difficult to keep. The House version of their American Health Care Act (AHCA) has been so heavily criticized that even President Trump says it is too harsh. Republican Senators are currently negotiating their version in secret to avoid too much scrutiny. So far, the Republicans are far from reaching consensus on how to proceed. The people of the United States, on the other hand, are clear on the solution to the health care crisis that they support and are organizing from coast to coast to make it a reality.
The public demand for a National Improved Medicare for All single-payer health care system in the United States is stronger than it has been in decades. The failures of the ACA to cover everyone and control rising health care costs, combined with the threat of the AHCA, which would add at least 23 million more people to the 29 million currently uninsured and further erode the quality of health insurance, have made it clear that we can't continue with the current health care system. This brings to mind a quote by Winston Churchill: "You can always count on Americans to do the right thing -- after they've tried everything else."
All other industrialized nations have some form of publicly funded universal health care system. Many of them are national insurance systems like our Medicare. Some, like the systems in Canada and Taiwan, are actually modeled on US Medicare. Most of them spend half as much on health care (per person per year) as the United States, and they have better health outcomes. No country has adopted a universal health care system and then gone back to its previous system. They have learned that when a system is universal, it is of higher quality precisely because every person has a stake in making it the best it can be.
People from across the political spectrum are expressing support for a single-payer health care system in the US, from conservatives like Charles Krauthammer to business leaders, such as Warren Buffett and Charlie Munger, to Senator Bernie Sanders. Given the failure of commercial media to cover single payer fairly, if at all, and given many Democrats' attempts to obfuscate it with a public option, there is confusion about exactly what a national improved Medicare for All system is and what it isn't. So, here is a primer on the basics of the single-payer health care system envisioned in Rep. John Conyers' bill, HR 676: The Expanded and Improved Medicare for All Act, which now has more cosponsors than ever before.
National Improved Medicare for All
National Improved Medicare for All (NIMA) is a universal publicly financed health care system. Here are the core elements:
1. National: Every person living in the United States and its territories -- including every health professional -- is in the system. No matter where people travel domestically, they are in the system. No one has to worry about going "out of network" because it is one giant network. This also means that if there is a medical center that specializes in a particular condition, patients can go there if they need to -- no matter where they live.
Including everyone in one giant risk pool spreads the risk widely so that no particular state is burdened more heavily than others with covering the cost of care for its residents. In the US, 20 percent of the population has high health needs, using 80 percent of our health care dollars. Fifty percent of the population is healthy, using only 3 percent of our health care dollars. However, any of us can become one of those in the top 20 percent if we have a serious accident or illness. Having a national system gives us the security of knowing that it is there for us when and if we need it. And including everyone increases the likelihood of preventing and controlling epidemics of infectious diseases.
2. Improved: This plan is an improvement over Medicare -- not simply an expansion of our current Medicare system. First, it is more comprehensive than current Medicare and includes all medically necessary care, such as mental health, dental, vision, hearing, rehabilitative and long-term care, medications and medical devices. Current Medicare excludes long-term care, so seniors are forced to spend down their assets before they qualify under Medicaid for long-term care. That would no longer be the case under National Improved Medicare for All. Moreover, the question of what is "medically necessary care" would be answered by patients and their health professionals without interference from health insurers who are more concerned with profits than the health of their enrollees.
Second, because the improved Medicare for All plan is comprehensive, supplemental health insurance would not be necessary, and would not be permitted to duplicate what is covered by the health care system. This is important for maintaining a high standard of quality: There should not be a private system for the wealthy and a public system for the rest of us.
One of the reasons that our current health care system is so expensive is because there are hundreds of different insurance plans with different rules and networks. This makes our current system heavily bureaucratic. Some hospitals have more billing agents than nurses, and physician offices spend more than 10 percent of their overhead dealing with our complex system. The US spends a third of its health care dollars on administration while other countries spend less than half of that, and traditional Medicare spends less than 5 percent on administration. Those dollars that are being wasted on paperwork could go to health care instead.
Moreover, our heavily bureaucratic system also takes our physicians' time and attention away from patient care. A Harvard study published last fall in the Annals of Internal Medicine found that for every hour of direct patient care, physicians spend two hours on paperwork. NIMA means there would be one system with one set of transparent rules, making it simpler for patients and health professionals alike.
Third, because of the savings inherent in a National Improved Medicare for All health system, out-of-pocket costs, such as co-pays and deductibles, would not be necessary. When people need health care, it would no longer be a financial decision; they would be able to seek care. Currently, more than half of insured people with moderate to low incomes are unable to afford their deductibles, and 2 out of 5 report delaying necessary care because of the cost. Every year hundreds of thousands of families declare personal bankruptcy because of medical illness; almost 80 percent of them had some form of health insurance.
There is an idea promoted by people who believe that health care belongs in the market that patients need to pay out of pocket before receiving health care. They call it "skin in the game" and say that it makes patients better "consumers" of health care. In reality, studies have demonstrated that out-of-pocket costs cause people to delay or avoid medically necessary care, leading their ailments to worsen and require more expensive treatment. Most people, no matter what their educational background, are not able to reliably determine which symptoms are important and which aren't; therefore, they are as likely to delay necessary care as they are to delay unnecessary care.
3. Medicare for All: NIMA is similar to traditional Medicare in that it is financed up front through taxes. Supporters strongly recommend a progressive tax because the US has a low ranking globally when it comes to fairness in health care financing. People at the lower end of the income spectrum pay a larger proportion of their income on health care than those at the top. Paying for health care through a tax makes the cost more predictable for families and businesses. It would replace the cost of health insurance premiums, co-pays and deductibles, saving money for 95 percent of the population.
However, instead of being only for people who are 65 years of age and older or for people who have disabilities, National Improved Medicare for All would cover everyone from birth to death. Under NIMA, when people enter a health facility, the first question they're asked is not, "What insurance do you have?" It is "Why are you here?" Those who do not have a national insurance card are presumed to be covered. Care is given first, and registration in the system comes later.
A single-payer system operates on the assumption that all people should be able to easily access the care they need, regardless of their wealth or income.
We Don't Have a Health Care System
One of the first concerns that people have when they hear about National Improved Medicare for All is that it would be too expensive to cover everyone with comprehensive benefits. The reality is that it is too expensive to continue with the system we have now.
The current system was never designed to be an actual health system; it is an accident of history. After World War II, employers were not allowed to raise wages, so they offered benefits, including health insurance, to employees instead. Tying health insurance to employment has proved problematic because when employees become very sick and can't work, they risk losing their job and health insurance. This connection also prevents people from retiring before they reach Medicare age. And the cost of health insurance is the number one concern of small and medium-sized businesses.
Another significant point in history was the Health Maintenance Organization Act of 1973 signed into law by President Nixon. This allowed entities to profit from health care and it unleashed a predatory industry. Private health insurers in the US are financial tools designed to make profits for their investors, making them very different from health insurers in many other nations, which are instead designed to pay for health care. Private insurers in the US make profits by charging the highest premiums they can get away with, shifting as much of the cost of care onto individuals as they can and restricting and denying payment for care. This approach is not compatible with providing high-quality care. In fact, private insurance companies are often obstacles that prevent patients from receiving medically necessary care.
It isn't only the patients who suffer in this system. Health professionals do, too. Physician burnout was one of the top two concerns identified by the Surgeon General last year.
The US's current hodgepodge of a system is the most expensive in the world, with the highest prices for health services and pharmaceuticals. The US isn't even the best, not by far. A recent global health study compared nations on 31 conditions. The US came in 35th with 14 Ds and Fs in critical areas, such as maternal and infant health, certain cancers, chronic conditions, such as Diabetes Mellitus, high blood pressure, heart disease, strokes, kidney disease and adverse reactions to medical treatment. The US has also been found to have high numbers of preventable deaths, estimated at over 100,000 per year, and a decreasing life expectancy.
One of the major strengths of National Improved Medicare for All is that it creates a coherent health care system that sets health for everyone -- not profits for a few -- as the bottom line. In addition to significant administrative savings, estimated at $400 to $700 billion a year, the system can negotiate for fair prices for health services and pharmaceuticals. The system can also engage in better health planning. Instead of rationing people's care based on ability to pay, the system can prioritize and truly address health needs.
No system is perfect. Ask people in countries with universal systems and you will always hear some complaints. But you won't hear about millions of people left without access to care, or families going bankrupt because of an accident or illness, or people delaying necessary care because of the cost. Once the US achieves National Improved Medicare for All, there will still be constant work to do to improve it.
Imagine for a moment the profound meaning of the US adopting a universal health care system. Public policies of the past few decades have overwhelmingly benefited the wealthy. NIMA would put forth a different set of values. It would prioritize people's well-being over corporate profits. It would also communicate that all people deserve the same access to high-quality health care. Previous efforts at universal health care in the US were stymied by racism and classism. A single-payer system would create a sense of social solidarity that has not been experienced in the US. Other countries have figured out that welfare systems are poor systems and universal systems are higher-quality systems, because each person has a stake in making them the best that they can be.
Achieving National Improved Medicare for All will be a profound transformation for the United States. It will empower us to fight for other necessities, such as education, a clean environment, a living income and more. And it is within reach.