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An Alternative to Medicare for All

Published:January 23, 2019DOI:https://doi.org/10.1016/j.amjmed.2019.01.007
      Two facts about US health care are beyond dispute. First, US health care is the most expensive in the world; it is twice as expensive as the average industrial nation.
      Organization for Economic Co-operation and Development (OECD)
      Health Expenditures.

      NBC News. Boehner: Affordable Care Act can't be fixed. Available at: http://www.nbcnews.com/vodeo/nbc-news/535543389. Accessed December 18, 2018.

      Second, US health care is not the best health care system in the world. Four different studies have compared US health care to other industrialized nations. As shown in Table 1, the United States has not fared well in these reports.
      • Blendon RJ
      • Kim M
      • Benson JM
      The public versus the World Health Organization on health system performance.

      Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. Available at: https://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror-2014-update-how-us-health-care-system. Accessed December 22, 2018.

      GBD 2016 Healthcare Access and Quality Collaborators
      Health care access and quality collaborators. Measuring performance on the health care access and quality index for 195 countries and territories.
      Table 1Ratings of Health Care
      ReportYearRating of United States
      World Health Organization
      • Blendon RJ
      • Kim M
      • Benson JM
      The public versus the World Health Organization on health system performance.
      200017/17 industrial nations
      Commonwealth Fund

      Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. Available at: https://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror-2014-update-how-us-health-care-system. Accessed December 22, 2018.

      201411/11 industrial nations
      GBD collaborators
      GBD 2016 Healthcare Access and Quality Collaborators
      Health care access and quality collaborators. Measuring performance on the health care access and quality index for 195 countries and territories.
      201629/195 nations
      In the United States, life expectancy is shorter, immunization rates are lower, and infant and maternal mortality are much higher than in other Organisation for Economic Co-operation and Development (OECD) nations.
      Organization for Economic Co-operation and Development (OECD)
      Health Expenditures.
      Our poor health outcomes reflect the fact that unlike other industrialized nations, many Americans lack access to ongoing medical care because they do not have health insurance. Prior to the passage of the Affordable Care Act (ACA) in 2014, there were 47 million uninsured Americans. In 2018, 4 years after the ACA was enacted, 27 million were uninsured.
      • Keith K
      Two new federal surveys show stable uninsured rate.
      Americans without health insurance receive suboptimal health care. They are less likely to have a usual source of health care, less likely to fill prescriptions, and more likely to postpone or go without care due to cost.
      • Keith K
      Two new federal surveys show stable uninsured rate.
      In addition, those who are uninsured are less likely to have preventive screening tests for cancer, including mammograms, pap smears, and colonoscopies.
      Organization for Economic Co-operation and Development (OECD)
      Access to Care.
      Patients with chronic conditions such as heart disease, diabetes, and asthma who lack a regular source of health care are at a greater risk of premature mortality than those who are insured.

      Kaiser Family Foundation. Key facts about the uninsured. Available at: https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed December 22, 2018.

      The impact of not having health insurance is illustrated by Table 2, which compares Canadians (all of whom have access to health care) to Americans who do or do not have health insurance.
      • Lasser KE
      • Himmelstein DU
      • Woolhandler S
      Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
      Table 2United States vs Canada
      • Lasser KE
      • Himmelstein DU
      • Woolhandler S
      Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
      United States
      CanadaInsuredNot Insured
      Regular doctor85%85%40%
      Doctor visit within 1 year83%86%56%
      Can afford prescriptions95%92%72%
      Note that Americans who are insured have the same access to health care as Canadians. However, Americans without insurance have less access to care.
      The most concerning fact about those who are uninsured in the United States is that they do not live as long as those who are insured do, which is shown in Table 3.
      Table 3Annual Mortality of Uninsured Americans Compared to Insured
      StudyYearIncreased Mortality (%)
      Franks et al
      • Franks P
      • Clancy CM
      • Gold MR
      Health insurance and mortality.
      199325%
      Institute of Medicine
      Institute of Medicine
      Care Without Coverage, Too little, Too Late.
      200325%
      Wilper et al
      • Wilper AP
      • Woolhandler S
      • Lasser KE
      • McCormick D
      • Bor DH
      • Himmelstein DU
      Health insurance and mortality in US adults.
      200940%

      How Can We Ensure That All Americans Have Access to Health Care?

      There are 2 ways to ensure that all Americans have access to health care. One way is for the US government to directly deliver health care to the population as in the UK and in Scandinavian countries; this is socialized medicine. In this system, the government owns and operates the hospitals. Health workers are government employees. The cost of health care is paid from taxes. Health care is free to all citizens. Socialized medicine works well in England and some other countries. However, it is exceedingly unlikely that socialized medicine could ever be accepted in the United States. The second way to make health care available to all citizens is national health insurance. All citizens are required to purchase health insurance, usually via employment. National health insurance began in Germany and is in place in multiple nations.
      Canadian health care is a hybrid of these 2 systems. Health care is paid from taxes and is delivered without charge to the patient. However, unlike in the UK, health care is delivered by the private sector. The hospitals are not owned or operated by the government, physicians are not government employees, and they charge the health insurance for patient care.
      Many Americans do not realize that the United States has had mandatory national health insurance ever since Medicare was enacted in 1965! US citizens and permanent legal residents (and their employers) must pay for Medicare through a salary deduction beginning with their first paycheck and continuing for as long as they earn income. Medicare is administered by the US federal government.

      Centers for Medicare and Medicaid Services. Medicare and you 2018. Available at: https://www.bettermedicarealliance.org/sites/default/files/217-09/cms-medicare-and-you.pdf. Accessed December 20, 2018.

      In 2018, the health care expenses of 57 million Americans were paid by Medicare. More than 600,000 physicians participate in the program, and nearly all US hospitals care for patients with Medicare.

      Centers for Medicare and Medicaid Services. Medicare and you 2018. Available at: https://www.bettermedicarealliance.org/sites/default/files/217-09/cms-medicare-and-you.pdf. Accessed December 20, 2018.

      The administrative costs and all overhead costs of nonprofit Medicare are much less than private insurance.
      • Woolhandler S
      • Campbell T
      • Himmelstein DU
      Costs of health care administration in the US and Canada.
      • Blendon RJ
      • Bensom JM
      The public and the conflict over future Medicare funding.
      Medicare differs from mandatory health insurance in countries like Germany and France because except for those with chronic disabilities, it cannot be used to pay for health care until age 65.

      Centers for Medicare and Medicaid Services. Medicare and you 2018. Available at: https://www.bettermedicarealliance.org/sites/default/files/217-09/cms-medicare-and-you.pdf. Accessed December 20, 2018.

      One of the major objections to Medicare for all is that it would be mandatory and would be administered by the federal government. In 2017, 82% of Americans said in a Pew Research poll

      Pew Research Center. Public trust in government 1958-2017. Available at: https://www:people-press.org/2017/12/14/public-trust-in-government-1958-2017. Accessed December 20, 2018.

      that they do not trust the US federal government. Yet, polls of Americans are strongly supportive of Medicare, even though it is mandatory and administered by the federal government.
      • Blendon RJ
      • Bensom JM
      The public and the conflict over future Medicare funding.

      Possible Solutions: Medicare-for-All

      If Medicare-for-all were enacted, it would pay the medical expenses of all Americans. Private health insurance provided by employers or individuals, Medicaid, or for veterans would cease to exist. The number of uninsured Americans would decrease to a bare minimum. Once all Americans have access to ongoing medical care, we could expect that most health disparities could be corrected.
      Many report that implementing a Medicare-for-all nonprofit system would significantly reduce administrative costs, profits, and overhead and would lead to a reduction in US health care costs.
      • Woolhandler S
      • Campbell T
      • Himmelstein DU
      Costs of health care administration in the US and Canada.

      Would Medicare-for-All Be Passed by Congress?

      There would be fierce opposition to a Medicare-for-all program. The Republican resistance to a governmental role in health care is deep and persistent as evidenced by their opposition to Medicare in 1965 and the ACA in 2010.
      • Dalen JE
      • Waterbrook K
      • Alpert JS
      Why do so many Americans oppose the Affordable Care Act?.
      A survey in 2014 asked, “Is making sure all Americans have health coverage a responsibility of the federal government?” Although 70% of Democrats said “yes,” only 12% of Republicans responded in a like manner.
      • Blendon RJ
      • Benson JM
      Voters and the Affordable Care Act in the 2014 election.
      Health care is the largest industry in the United States with 16 million health workers.
      • Thompson D
      Health care just became the US's large employer.
      Millions of these health care workers in the health insurance business, pharmaceuticals, for-profit health management organizations and hospitals could lose their jobs. They would certainly oppose Medicare-for-all and would be a powerful adversary.
      There would be massive advertising opposing Medicare-for-all, just as there was to the ACA. It would be called socialized medicine (it is not!) or government-style medical care with waiting lists.
      • Dalen JE
      Should the Affordable Care Act of 2010 be repealed?.
      It is unlikely that such a massive change in our health care system would be passed by Congress at the present time.

      Alternatives to Medicare-for-All

      One possibility would be to lower the current age at which Medicare begins to pay for medical care from 65 to perhaps age 45. This would increase the costs of Medicare and would require an increase in the Medicare payroll tax to employees and employers. The current deduction for Medicare is 1.45%-2.35% for the employee and 1.45% for the employer.
      • Woolhandler S
      • Campbell T
      • Himmelstein DU
      Costs of health care administration in the US and Canada.
      Increasing the Medicare tax would face strong opposition.

      Another Alternative to Medicare-for-All

      The number of patients receiving Medicare could be increased by letting some Americans “buy into” Medicare. They would pay an increased Medicare tax until they reach 65, at which time they would pay the same as others for Medicare coverage. Because they pay their way, this should not increase Medicare costs.
      Buying into Medicare before age 65 would be optional and not mandatory.
      Those pleased with their coverage by employment-based insurance or other private insurance could keep their current insurance. Those not pleased with their current coverage or those without insurance could elect to buy into Medicare.
      If buying into Medicare were successful, it could pave the way for Medicare-for-all. Many Americans oppose change, but our health care system must change. The United States cannot continue to have a health care system that is the most expensive in the world and yet leaves many Americans uninsured and without lifesaving, ongoing, and preventative care.
      We can, and must, do better!

      References

        • Organization for Economic Co-operation and Development (OECD)
        Health Expenditures.
        In: Health at a glance (2017): OECD indicators. OECD Publishing, Paris, France2017: 131-144
      1. NBC News. Boehner: Affordable Care Act can't be fixed. Available at: http://www.nbcnews.com/vodeo/nbc-news/535543389. Accessed December 18, 2018.

        • Blendon RJ
        • Kim M
        • Benson JM
        The public versus the World Health Organization on health system performance.
        Health Aff (Millwood). 2001; 20: 10-20
      2. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. Available at: https://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror-2014-update-how-us-health-care-system. Accessed December 22, 2018.

        • GBD 2016 Healthcare Access and Quality Collaborators
        Health care access and quality collaborators. Measuring performance on the health care access and quality index for 195 countries and territories.
        Lancet. 2018; 391: 2236-2271
        • Keith K
        Two new federal surveys show stable uninsured rate.
        Health Affairs Blog. 2018;
        • Organization for Economic Co-operation and Development (OECD)
        Access to Care.
        Health at a glance (2017): OECD indicators. OECD Publishing, Paris, France2017: 88-96 (OECD Publishing)
      3. Kaiser Family Foundation. Key facts about the uninsured. Available at: https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed December 22, 2018.

        • Lasser KE
        • Himmelstein DU
        • Woolhandler S
        Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey.
        Am J Public Health. 2006; 96: 1300-1307
        • Franks P
        • Clancy CM
        • Gold MR
        Health insurance and mortality.
        JAMA. 1993; 270: 737-741
        • Institute of Medicine
        Care Without Coverage, Too little, Too Late.
        The National Academies Press, Washington, DC2002
        • Wilper AP
        • Woolhandler S
        • Lasser KE
        • McCormick D
        • Bor DH
        • Himmelstein DU
        Health insurance and mortality in US adults.
        Am J Public Health. 2009; 99: 2284-2295
      4. Centers for Medicare and Medicaid Services. Medicare and you 2018. Available at: https://www.bettermedicarealliance.org/sites/default/files/217-09/cms-medicare-and-you.pdf. Accessed December 20, 2018.

        • Woolhandler S
        • Campbell T
        • Himmelstein DU
        Costs of health care administration in the US and Canada.
        N Engl J Med. 2003; 349: 768-775
        • Blendon RJ
        • Bensom JM
        The public and the conflict over future Medicare funding.
        N Engl J Med. 2013; 369: 1066-1073
      5. Pew Research Center. Public trust in government 1958-2017. Available at: https://www:people-press.org/2017/12/14/public-trust-in-government-1958-2017. Accessed December 20, 2018.

        • Dalen JE
        • Waterbrook K
        • Alpert JS
        Why do so many Americans oppose the Affordable Care Act?.
        Am J Med. 2015; 128: 807-810
        • Blendon RJ
        • Benson JM
        Voters and the Affordable Care Act in the 2014 election.
        N Engl J Med. 2014; 371: e31
        • Thompson D
        Health care just became the US's large employer.
        The Atlantic. January 9, 2018; (Available at:)
        • Dalen JE
        Should the Affordable Care Act of 2010 be repealed?.
        Am J Med. 2011; 124: 575-577