Can Medicare for All Succeed?

By Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D.
The Nation, Letters, August 16, 2017

Joshua Holland’s anti–single payer screed (“Medicare for All Isn’t the Solution for Universal Health Care”) is so riddled with misinformation and outright errors that it makes one wonder whether The Nation has laid off its fact-checkers.

Just one example: In arguing the impossibility of a health-care transformation in a high-spending nation, Holland claims that Switzerland’s health expenditures in 1996 amounted to only 5 percent of GDP. The correct figure is 9.2 percent. [Editor’s Note: This has been corrected in Holland’s article.]

He suggests that cost control under single payer requires halving doctors’ incomes, a serious political problem if it were true. But Canadian doctors make about 80 percent what their US counterparts do, and, taking into account their lower educational debt and post-retirement health expenses (more than $250,000 per couple in the United States), they’re about as well off financially as their US counterparts. Moreover, most US single-payer projections foresee increased spending on physician visits once copayments are abolished, and simplified billing would reduce the bite that office overhead takes out of doctors’ take-home pay.

Holland falsely claims that no one has provided guidance on the transition to single payer. We, and our colleagues in Physicians for a National Program have published in the Journal of the American Medical Association, The American Journal of Public Health, and the New England Journal of Medicine several quite detailed proposals laying out transition plans for acute-care financing, long-term care, and quality monitoring; another, on prescription-drug regulation and financing, is in the works. We’ve analyzed in detail the likely shifts in administrative costs and employment, and the federal single-payer legislative proposals include funding for job retraining and placement and income support to transition the million or so insurance and administrative workers who currently do useless bureaucratic work and whose jobs would be eliminated under single payer. While the transition would be disruptive for some administrative workers, it would be simple for hospitals (they’d stop billing for each patient, Band-Aid, and aspirin tablet and instead be paid lump-sum budgets), and a welcome relief for doctors and nurses, who suffer record high burnout rates in the current medical-industrial complex. That’s why recent polls show that around half of doctors favor single payer (and 21,000 of them have joined Physicians for a National Health Program), and National Nurses United, the leading nurses’ union, is the nation’s strongest single-payer proponent.

Most egregiously, Holland misrepresents the single-payer legislation that’s actually been proposed, citing Medicare’s deficiencies to smear reform proposals. As the title of John Conyers’s bill H.R. 676, the Expanded & Improved Medicare for All Act, makes clear, that legislation would upgrade Medicare coverage, eliminating copayments and deductibles, and fix its other flaws. Holland suggests that, since many Medicare recipients supplement their coverage with private policies, such legislation would boost out-of-pocket costs for millions who currently have employer-paid coverage or Medigap policies. In fact, virtually no one would face increased copayments or deductibles under H.R. 676 (or Bernie Sanders’s forthcoming legislation, or the many state bills), although wealthy Americans’ taxes would rise. And few people would complain about being freed from insurers’ narrow provider networks; not one of the Medicare Advantage plans, without out-of-pocket benefits, covers care at New York’s Memorial Sloan Kettering Cancer Center. Under single payer patients could, as in Canada, choose any hospital or doctor.

Holland’s scare-mongering about the chaos likely to ensue during a transition to single payer echoes The Wall Street Journal’s dire predictions of “patient pileups” and other disasters at the dawn of Medicare in 1965. It didn’t happen then and wouldn’t happen now. Medicare, sans computers, enrolled 18.9 million seniors (displacing private insurance for many of them) within 11 months of its passage.

The real enemies of single payer aren’t the disgruntled patients or doctors whom Holland features but the insurance and pharmaceutical firms that he barely mentions. That powerful opposition is the real problem we have to overcome, not the imagined chaos of the transition or the phony fear that patients would revolt against better coverage.

The authors are primary-care physicians, distinguished professors of public health at the City University of New York at Hunter College, and lecturers in Medicine at Harvard. They founded Physicians for a National Health Program and served as health-policy advisers during Bernie Sanders’s presidential campaign.