Although Medicare for all seems to have gotten buried by politicians who label it as “socialistic,” it’s still an important idea that could be feasible if we approached it from a fresh perspective.
As patients, we may reflexively see Medicare for all as a panacea that would effectively remove most of our concerns about how to pay for our health care. But on the other hand, we may not realize the inherent hazard of thereby possibly receiving too much health care.
I believe that an immediate switch to Medicare for all wouldn’t be sufficient or even the right place to start. This would not come close to addressing the bigger problem of some people getting far more medical care than they need, while others have trouble even accessing the health care system equitably.
In fact, studies show that there are so-called “super-utilizers” who typically visit the hospital four or more times a year—usually in the ED. They are often, but not always, uninsured, or on Medicare or Medicaid. The cost to treat these chronically ill patients is particularly high. In a 2017 study this group comprised just 5 percent of all patients but accounted for half of the country’s health care spending, with 1 percent accounting for 22 percent of health care spending, and the bottom 50 percent of the population, ranked by health care expenditures, representing just 2.9 percent of health care costs.
Studies show that a strong personal connection with a primary care physician can lead to lower health care costs, better health and a full halving of average mortality risk! See my recent book for a more fully developed argument in support of the health benefits of a sustained patient-physician relationship. (The Healing Connection: A Partnership for Your Health).
Those of us working within the health care system are understandably leery of our federal government playing such a dominant role. Medicare for all would not guarantee that most people would develop such a relationship with a personal doctor. In fact, the Centers for Medicare and Medicaid Services (CMS) has adopted the currently ascendant, but to my mind demeaning, use of “consumers” and “providers” when referring to suffering patients and their physicians. Additionally, CMS has repeatedly demonstrated a propensity for resorting to simply cutting physician payment rates as their “go-to” cost containment intervention.
I was therefore heartened by the innovative approach presented in Ken Terry’s 2020 book, Physician-Led Healthcare Reform: A New Approach to Medicare for All. The longtime health care journalist presents an extensively researched, heavily referenced, and convincing argument for why we need a single payer system, particularly one that focuses on “resuscitating primary care.”
As an emergency physician, I find myself entirely in agreement with the concerns that we need to both reduce waste in the system, which is estimated at about 30 percent of health care spending, and also optimize patient care. It will likely take the properly applied single-payer power of the federal government to counterbalance the dollar-driven decision-making of private equity, pharmacy benefit managers, health care executives, health insurance companies, and some hospital administrators. Medicare for all, if done right, could help us reach both goals while curbing cost growth. We should neither excessively glorify nor demonize the Medicare for all concept.
Primary care physicians (PCPs) are in the best position to guide patients to make wise decisions on critical factors such as appropriate diagnostic testing and consultations with specialists; patient engagement in their own health care; and the critical role that the social determinants of health play in either exacerbating or ameliorating illness and disease. PCPs are currently demonstrably overworked, relatively underpaid and becoming scarcer.
Terry’s argument mandates that we shouldn’t make the jump to single-payer unless physicians lead the way in transforming the system, that a transition to a single-payer system would require up to a decade to work out and cannot simply be imposed overnight by the government fiat. A sustainable model of national health insurance, he says, should give PCPs the opportunity to maintain or improve their incomes by sharing in the savings they create.
In conclusion, Terry writes, “Eventually, the current health care system will be swept away when it becomes unaffordable to enough people. The question is whether we’ll end up with something much better or something much worse.” Having considered how he fully fleshed out his envisioned path to “much better,” I read his book as promoting a cautious optimism. I fully share and believe most readers will also share this hopefulness, as well as his concerns that though this challenge can be faced and mastered, the jury is still out on whether we will muster the societal consensus required to do so.
Drew Remignanti is an emergency physician.
