The New Bloodletting: Why We Need Medicare-for-All not Exploitation-by-Few

In brief: The US healthcare system is unjust and kills people each year. It’s also one of the most innovative but only if you can afford it. Health and Human Services Secretary Tom Price, MD, aims to remove full coverage from many so that most can be bled for capital. Socialism offers more than one alternative to this exploitation.

In opening his primer on US Health policy, Donald A. Barr, MD, PhD, juxtaposes two statements and asks students which is true: is it that the US has one of the best healthcare systems in the world or is it the worst healthcare system among developed nations? His rhetorical trick is that both statements are true; the former for innovation and some outcomes with regard to medicine and the latter when looking at how many people go without care due to lack of coverage as well as prohibitive cost of care.

Secretary Price sides with neither and offers a system that forces many out while continuing to profiteer from the impossible choice of deeper debt or ignoring health. Think bloodletting but with “market-based” solutions as the leech. This gilded age mentality is a common thread from Trump’s team: from Bannon to Sec. Price, MD to Sec. DeVos: the best awaits those who pull themselves up by their bootstraps, one million dollars at a time.

Healthcare policy in the United States is a Rube Goldberg device. It’s not complex for the sake of improving people’s health, it’s complex for its own sake. Years of lobbyists, special interests, and an industry association that thinks Grandma on the operating room table is a lot like purchasing sneakers. The American Medical Association once described flat salaries and insurance coverage instead of fee-for-service as being a “medical soviet.”

Lesson #1: Americans pay more for less.

In the US, we have a mix of public and private, federal and state, profit and nonprofit groups involved in the financing of care. The single largest federal program is Medicare ($646.2 bn), followed by Medicaid ($545.1 bn). Insurance paid for by private employers and individuals covers most of the rest ($1,031 bn). Altogether, the US pays around $9,086 per year per person. However, that’s only if the aid were evenly distributed. As of late 2015, 8.9% of the population (28.5 mn) lacked coverage.

The runner-up, Switzerland, a single-payer nation, spends 30% less per year, per person and for a system that covers a larger portion of people within its borders. If to you that sounds like a bad deal, it is. All too often, it means nothing for the working class and severe restrictions on the elderly population covered by Medicare and further marginalized on Medicaid. In many cases, these people will still pay out of pocket ($338.1 bn).

Lesson #2: No one plans on emergency except those profiting from it.

The AMA largely represents the interests of many health professionals. However, it has considerable weight from private practices and for-profit groups. They championed fee-for-service health care models and are eager to return to what Price refers to as a “physician-patient relationship” regarding financing, the kind where a provider bills patients directly. The AMA has fought any form of insurance: public or private as well as reforms to curb costs many lucrative fields, such as emergency rooms ($1,036.1 bn, growing 5.6% in 2015). They’ve fought every attempt at government-led coverage from both Roosevelts to Eisenhower and remained highly skeptical of federal funding including Medicare under President Johnson.

Lesson #3: US Healthcare is rationed by the size of one’s purse, not need for care.

The rationing of healthcare by pocketbook is a moral failing. We’ve created income-based death panels for the working class. It’s absurd that people should choose between poverty and further illness.

Even in capitalism’s own terms, health coverage is not a rational choice. The knowledge of a patient is asymmetrical to the system they’re seeking care in and very few Americans will let Grandma be the opportunity cost for keeping their house. We’ll go into poverty to save our family and ourselves.

The model Secretary Price has at times championed includes balance billing, wherein providers bill and the difference between what insurance negotiates and any remainder is left for the patient to pay. This is currently prohibited for Medicare patients. There’s great risk of abuse in this system as unscrupulous providers might inflate charges to maximize what insurance will allow as well as what patients can afford.

This is worsened by narrow networks now provided by private insurers. These narrow networks mean some practitioners at a care site may be out-of-network, despite the care site and group being listed otherwise. This is not to blame healthcare professionals; the labyrinthine dozens of types of coverage per insurer leads to working longer, more stressful hours treating patients. Ours is systems that values the margins on revenue, not the people at the margins of dire health.

I say margins and not profit because seven of the top 10 largest margins are from US hospitals that are so-called non-profits. Even some non-profit insurers abuse the term and limit care covered. In California, for example, a former executive spent hundreds of thousands on bowling, hotels, and drinks with a Sharknado cast member. This was not enough to lose their tax-exempt status; it took years of massive rate hikes and large margins leading this insurer for that to happen. Despite these actions increasing tax liability to $392mn from $78mn, they still pulled in margins of $162mn that year, a small drop from 2013.

The average person footed the bill through higher premiums, denied claims, and narrower networks during design of the following year’s insurance plans. No, nonprofits are not our friends. Even when they work for the greater good (and they do some amazing work), the ends of nonprofits can be achieved best and at scale through public ways and means.

Lesson #4: Socialism offers many distinct alternatives, all of which place life above the strife of debt and lack of care.

The resentment many feel toward private insurance represents an area where socialism offers everyone, including medical practitioners, the chance for greater transparency, democracy, and savings. Indeed, a majority of voters want an expanded federal role in paying for coverage, even more than want to keep the ACA.

• In Canada, goverment provides coverage while private practices deliver healthcare. This is called monopsony, as private practices are still market-based.
• In the United Kingdom, the government provides both coverage and the delivery of care through the National Health Services.

Each of these examples regulates to ensure best practices and to prevent abuse. While not perfect, monopsony is the easiest for Americans to think of due to Medicare providing near-universal coverage for seniors. Medicare-for-all has cachet already.

Lesson #5: Fair pay for providers and promoting primary care, care management are the hurdles outside ideology.

From some providers, there are reservations about reimbursement under Medicare-for-all. From the mid-1990s through early 2010s, the Sustainable Growth Rate (SGR) served as federal reimbursement for Medicare. This rate wasn’t enough to adequately reimburse labor from all fields within medicine. It led to yearly hemming and hawing from Congress with the threat from providers of pulling out of Medicare programs. While rightfully frustrating, this is a challenge not unique to the US.

The SGR’s replacement, MACRA, attempts to solve these reimbursement issues with a simultaneous goal of driving better value per healthcare dollar through new compensation models. If successful, it removes one of the largest objections from all but the most right-wing libertarian medical providers. If we have rates providers can live on, we have one of the largest pieces for cutting the private sector overhead caused by private insurance.

In political terms, the Left, under something as mild but transformational as Medicare-for-All can offer an easy-to-understand system. It would have strong leverage over pharmaceutical companies and other would-be “bloodletters” accountable while not neglecting the labor rights of medical practitioners and dignity of patients. Socialism offers transparency in financing health care, negotiating rates, and is democratically accountable.

It’s not anathema, however.

Lesson #6: Medicare-for-All has and depends on the support of practitioners as much as patients.

Practitioners in monopsony, single-payer led systems and nationalized care and coverage systems (like the NHS), see labor strikes. Striking is a right. It is commendable. No one should settle for worse care for their patients nor unlivable wages or unsafe work conditions. In the US, too often our own nurses work longer hours without rest, back-to-back shifts, etc.

In fact, nurses are one of the strongest supporters of a universal coverage model within the delivery of healthcare. The largest US nurses’ union, National Nurses United, backed Sen. Sanders, a long-time politician from a small, predominantly rural home state, during the 2016 DNC Primary.

Many nurses understand the value of organized labor. They regularly fight for both their patients and their own dignity as workers. They also deal firsthand with the downsides of a deeply fragmented system. These problems include unexplained claim denials or disputes on bills long since past. Most nurses, I would argue, want to practice medicine, not accounting. Socialism is, I hope, one answer that to that.

Our nurses, doctors, and allied healthcare professionals deserve far better. More importantly, so do patients.

Ultimately, capitalism’s stranglehold on healthcare in the US does tremendous harm. Hospitals are bullish about Secretary Price’s plans. Bets are already lining up for the payoff to publicly-traded insurers and healthcare management corporations. With a secret bill in works, one should rightfully be skeptical of what House Republicans plan in 2017.

Donald Trump views himself as one of the greatest deal-makers ever. Bigly. If he were serious about cutting a deal on behalf of Americans, he’d reject calls to cut healthcare benefits. Our leadership should make one of the best deals society can offer. It should offer health and dignity for its sick and its tired, regardless of income. Trump’s not serious about that though. That’s why it’s up to us to demand dignity for patients and practitioners alike.