A Doctor’s Prescription

As the primary battles heat up, “Medicare for All” (or in Mayor Pete’s more “do-able” formulation “Medicare for All Who Want It”) has become perhaps the hot-button issue.

The Trump Administration continues to wage war on the Affordable Care Act, a/k/a Obamacare–part of Trump’s determination to erase anything and everything Obama accomplished– and thanks to Mitch McConnell’s success in placing partisans on the federal bench, that attack may succeed.

Anyone who follows the news, or has a Facebook feed, knows what we “consumers” think, and polling confirms that large majorities of Americans would welcome some form of national, universal healthcare. But what about doctors? What do medical professionals who have to work within today’s uneven patchwork of a system have to say?

I asked my cousin, the cardiologist whose insights I periodically share.

I encourage you to click through and read his post in its entirety, but I want to share several observations that I found particularly telling. The first is his reminder that we don’t go “shopping” for healthcare the same way we shop for a new pair of shoes.

Although comparison shopping makes sense when we buy a product like an automobile, such market forces do not apply to health care. Negotiation of prices of various treatments is seldom available, especially not for the complex needs of the desperately ill who consume a large share of resources. Multiple private insurance plans obscure this issue even further.

He then cites a recent study that found a significant part of the variation in medical spending–and more than half of all Medicare spending– to be determined by capacity rather than by medical need.

And speaking of cost…

In contrast to the ACA’s requiring private insurers to spend at least 80-85 percent of their revenue on delivery of health care, more than 98 percent of Medicare’s expenditures are so devoted. Estimates vary, but one-quarter to one-third of our current costs are driven by insurance company overhead, profits, and the administrative costs. Roughly half of these costs would be recovered under single-payer and could instead be devoted to the delivery of meaningful health care.

And then there are drug prices.

Drug prices must be controlled:  Acceptable drug lists vary widely among health plans. Negotiated prices depend strongly upon the buyers’ purchasing volume. Only a single-payer system enables the kind of unified bulk purchasing of drugs and medical devices that would give the buyer adequate power. A model for this structure exists today here in the Department of Veterans Affairs (VA). Due to governmental authority to negotiate drug prices for the VA, it pays roughly half the retail price of drugs.

I italicized that last sentence, because it astonished me. No wonder other countries allow government to negotiate drug prices–and we can all guess why Congress expressly forbids our government to do the same.

But what about doctors’ pay? Shouldn’t doctors’ incomes compensate them for those years of medical training and residencies? Wouldn’t we lose medical personnel under a national system?

A recent analysis found that a single-payer model does not lead to a loss in physician income, allowing for care-givers to receive adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers. Streamlined billing under single payer would also save physicians vast overhead costs, enhanced by reducing the need for the many employees to fulfill the varied requirements and forms of the private insurance companies. Moreover, physicians might best be compensated with regular salary-type payments rather than the current “fee for service” model, which encourages excess medical tests and procedures that drive up costs without providing better outcomes.

And finally, what about private insurance? Opponents of a single-payer system warn that people who love their current coverage (these are people I’ve yet to encounter, but I’ll assume for the sake of argument that someone, somewhere, actually likes Anthem, et al) would lose it. My cousin seems to be recommending Mayor Pete’s “Medicare for All Who Want It” approach. He also makes a point that Kamala Harris made in a recent interview:

The population of the U.S. would likely require additional tiers of care provided by private insurers, which might add extra services to basic care such as private room selections, lower waiting periods for non-urgent problems, elimination of co-pays, long-term care, dental care, etc.

The bottom line: the doctor has diagnosed America’s current approach to healthcare as deathly ill and probably terminal. You can read his prescription in its entirety at the link.


  1. Still thinking about medical care system. We now have Medicare/Tricare for life after my husband served many years in Army. Got out at 39 young enough to start 2nd career.
    We were in a Medicare system in Military and while under it all our needs were met just moved about every 3 years. It was something I will never regret seeing many countries and states. Had time of our lives. After we first got out I had culture shock. Husband went to trade school and became a Union Carpenter after 2 1/2 years of school. The whole time he was in school he worked so we had income and medical benefits that only got better.

  2. Bravo to your cousin for his very cogent explanation of this issue. The ACA was only the first step toward anything close to being sanity and fairness in the delivery of health care in this country. I’ve seen this up close for now nearly twenty years and given the angst of all the parents of the many, many pediatric patients that I worked with at Riley Hospital for Children anything that can lessen their burden which is akin to that of the elderly is an imperative. If we can just get past all those organizations that are standing in the way of this and those that they support who are corrupt elected officials we could end up “cooking on all burners” and have a health care system that is worthy of the people that it is supposed to serve and care for and which is also fiscally responsible.

  3. The key to Democrats winning office in the next election, in my opinion, will be keeping a national single payer health insurance option front and center. As we all know, far too many working Americans that have employer insurance can no longer afford to obtain the health care that they need due to high deductibles and co-pays.

    Obama’s original plan included a government single payer option for those who wanted to buy into a plan similar to Medicare or Medicaid that would allow lower income citizens to obtain health insurance at a price they could afford. Of course, he had to give up on that part in order to get the ACA passed.

    The insurance and pharma corporations have used their deep pockets to ensure the members of Congress will not vote for a single payer plan. However, since people like Bernie Sanders and Elizabeth Warren not only couldn’t be bought, but have become even louder in their quest to actually fulfill their duties of serving the citizens rather than corporate interests we are moving towards a government option for everyone.

    The republican attacks on expanded Medicaid and the ACA were a huge part of why they lost some seats in the last election, yet they continue to obey their donors who want to do away with health insurance for every citizen. They are losing this battle.

    One of the most egregious (in my opinion) abuses of taxpayer dollars by private health insurance corps has been their Medicare Advantage plans. These options have allowed them to bilk our government of billions of dollars through over billing and designating members as higher risk than they actually are. Anthem has been busy expanding their market share of Medicare Advantage plans because they have found these plans to be such an easy way to make huge profits. Those plans should never have been allowed to be created.

  4. Medicare for all, single payer insurance sounds good and would be good had it been established 40 years ago; after Nixon repealed the law against health care providers becoming for-profit businesses. The entire health care system and Big Pharma are now huge, million and/or billion dollar corporations. While I am against that system I need to know how this could be brought about TODAY? Will the government oust, take over or buy out these corporations by force to put health care coverage, all of its entities, into the hands of this government – even IF we rid the government of Trump? And that is a huge IF and growing daily. If anyone believes these health care corporations, including the super wealthy doctors, will willingly hand over their for-profit incomes; I hope they have coverage for mental health care. What is the actual feasibility of this change?

    Mayor Pete’s “Medicare for all who want it” is even questionable financially when our monthly Medicare premiums keep going up and coverage is dwindling away, this is true of those with other coverage, most with killing annual deductibles and high co-pays. I recently went through almost of month of battling United Healthcare when I attempted to seek information regarding a change in my coverage to find service closer to my home; with my incomplete application (necessary to acquire information regarding their coverage) they arbitrarily accepted me as a member on March 31st, activating my coverage on April 1st which canceled my current coverage without my knowledge or permission. The fight was on! Fortunately my current health care supported me and maintained me as being covered with no break in coverage from April 1st but it took 3 weeks for Medicare to replace my current coverage and remove the United Healthcare listing, they continued bugging me to complete my application and fill out their medical assessment. Are they really that desperate to drag in members? I’m sure those using United Healthcare are satisfied with their coverage; or maintain it rather than chance losing what health care they currently depend on.

  5. What happened to the comments I just submitted? Too arbitrary regarding the health care issue?

  6. I wonder how many of those who claim to “love” their existing health insurance (obtained through their employer) understand that their coverage is subject to the employer’s deciding to switch plans to save the money it contributes. These people have no say in what is provided. And, if the employer did not provide that coverage, the money it spends on it could be converted to salary upgrades (if the “shop” is a union shop, that is).

  7. C. Everett Koop analyzed our medical system and determined that costs could be significantly lower if we just used a universal reimbursement form for all insurances, both public and private. It would have been an easy thing to require, if anyone were really interested in lowering cost.

    As to the topic of the day, we do need to have a public option available. Medicare for all would require a ton of changes to Medicare that wouldn’t be able to pass today. Additionally, if we tried to do a Medicare for all program, we would be where we are today with the ACA, hoping Republican controlled courts don’t eliminate Medicare and Medicaid altogether.

    Just to make this a tiny bit political, if we don’t flip the Senate, we won’t get anything and will probably lose the ACA.

  8. Good article, but it misses a couple of points. First, while it is true that Medicare expends 98% on care, while private pay directs far more to profits, that is a little bit misleading. Medicare can expend 98% on care because it has other budgets it can use for investigation and enforcement. HHS-OIG, the FBI, State Medicaid Fraud Control Units, US Attorneys Offices, and local prosecutors all have a hand in Medicare oversight. There are dozens of other points in State and Federal budgets where money is used to support Medicare, creating the illusion of greater efficiency. It is still far more efficient than private insurance, but not as much as it appears.

    Second, while individuals don’t shop for specific incidents of medical care, there is significant shopping for insurers.

    Third, while I’m not opining on how much is enough, the following is, I don’t want to say “disingenuous,” but certainly pretty wishy-washy:

    “A recent analysis found that a single-payer model does not lead to a loss in physician income, allowing for care-givers to receive adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers.”

    It goes from saying there won’t be a loss of income to concluding that they’ll still make enough, according to whomever decides what “enough” means. The bottom line is simple – if all health care were paid at Medicare rates, there would be a significant decline in revenue for health care providers, including physicians. Will they still be among the most highly compensated professionals? Of course they will. Will they still make as much as they do now? Nope. Not a chance. Are we okay with that? Maybe. Maybe we prefer the most dedicated over the most successful. But we need to at least be honest about it.

    We also need to consider what happens to the entire field. Start with the fact that we can’t start from scratch. This isn’t post-war England, with the ability to rebuild from effectively nothing. We have, for good or for ill, an existing health care industry, and whatever we do will change it. If we suddenly cut all the private pay rates to Medicare rates, every rural hospital in America would close within the year. Without huge additional subsidies and a very long-term plan to change our entire delivery system, the effects would be felt the hardest where health care is already hardest to get.

    There are effective incremental solutions, but they’re politically nonviable. The right hates them because they involve government over private industry. The left hates them because private industry survives. But our choices are (a) keep a failing system, (b) wait for the system to fail so catastrophically that we recreate the whole thing, and accept all the consequences, or (c) create a solution that addresses core issues without creating additional crisis.

    One possible blended solution addresses one of the huge problems with the ACA – it only addresses a small percentage of the population, those who buy their own insurance. Most people didn’t care because most people weren’t affected. Here it is:

    1. Allow people 50 and over to buy into Medicare at cost, including an accurate assessment of total cost (see above, re other budgets supporting Medicare);
    2. Allow private companies to buy into Medicare for employees over 50, at the same costs;
    3. Allow Medicare to negotiate drug prices and give it more control over its formulary. I would add, strict price limits on drugs created through government research, under threat of (legal but rarely enforced) patent take-backs.

    That’s it. It’s that simple. What are the benefits?

    First, it will significantly reduce the age, and therefore increase the health, of people under private insurance umbrellas, driving down the costs of premiums.

    Second, it will significantly reduce the age, and therefore increase the health, of people under Medicare, driving down costs, on average, for the system while bringing in revenue that more than pays for the additional average care.

    Third, it gets private industry on board. If private companies can reduce their insurance costs by shifting older employees from Anthem to Medicare, they won’t care if it’s “socialist.”

    Fourth, it is a viable “free market” solution to all but the most devout conservatives, because it doesn’t force people to shift to Medicare. It allows them to do so, and they have to pay for it.

    Fifth, it will address the fastest-rising costs in health care, prescription drug prices, while giving the people the benefit of research paid for with taxpayer dollars.

  9. Sure. It’s the Republican way: Screw anything and everything that the brown guy put in place as well as the people he intended to help get through a productive life. The Republicans simply want more money available for their rich donors to feed to the stockholders and their immigrant gardeners.

  10. When physicians (AMA) support universal care, we’ll be on the way. They are saying one thing, but their union is doing another along with the millions spent by the insurance industry.

    We pay the insurance industry to lobby against us – what an amazing concept!!

    Once we get universal health, other industries better prepare themselves because of pollution, sugar, food, meat, etc. all having adverse effects on our health. This is why there is widespread corporate resentment against the idea.

    And don’t forget the corporate media who make millions off the ads for Big Pharma and Health Insurance.

  11. I believe single payer is the only way to significantly reduce the cost of healthcare – cost is the root problem to many of the issues and we pay about twice what we should be paying. I believe that “Medicare for all who want it” is the right answer –I believe it’s the fastest path to single payer. it’s probably the only politically achievable answer as well.

    I also believe that a two-tiered system (with supplemental insurance) is going to be necessary. We currently do a good job with high-tech (very expensive) interventions and do a poor job of universal basic care. Suggesting to people that they are going to have to give up some of their access to high-tech interventions so that we can provide more universal care isn’t going to go over well. BTW: Those arguments are already being made(“if we limit drug prices, we won’t have access to wonder drugs, etc.”)

    I still strongly believe that we can’t talk about “universal coverage”, “single payer”, “healthcare as a right”, etc. without a price tag. Simply dismissing the cost issue by saying that other countries do it ignores the reality that most countries which do are also struggling with cost and service levels. Right now, the estimate of that cost is $10k per person per year that individuals would pay in new taxes after subsidies (Bernie’s plan) and even that is probably too low because it assumes savings that likely will not materialize. That doesn’t sound reasonable to me.

    We need to move far away from the misconception and magical thinking that we will have unfettered access to all the healthcare that we want and someone else will pay for it. That’s simply not ever going to be the case.

  12. David Honig; excellent commentary. But…those of us with Medicare, which we still pay for out of our Social Security or SS Disability checks monthly, need a Medicare supplemental to pick up some…but NOT all of the slack…in our health care costs.

  13. All the above show how complicated both healthcare and radical change can be. This is without deep thinking about unintended consequences.

    One more toss into the brew, the hundreds of thousands of good paying jobs for people without college degrees in the private insurance industry…

  14. MEDICARE FOR AMERICA (Axios 4/10/19)

    The leading alternative to Sanders proposal, known as “Medicare for America,” would move more gradually and is not quite as robust as Sanders version — but would still be enormously different from what we have now.

    How it works: A new public program would automatically absorb the uninsured, all newborns, and everyone on Medicare, Medicaid, and the Affordable Care Act’s exchanges.

    • This version would be optional: Employers could keep offering coverage on their own, or pay to cover their workers through the public plan.
    • So your plan could change if your employer opted into the new system, and that means your doctor could, too. (Reminder: employers can already change their plans today.)
    • Over time, as more employers opt into the public system and people covered as newborns age into the workforce, “I think it’s a reasonable assumption that the employer market would deteriorate,” Levitt said.
    • This new version of Medicare would still have a role for private insurers, similar to what Medicare has now. They could create their own networks of doctors and hospitals.
    • Your costs: Middle- and upper-income households would still need to pay a premium, and some out-of-pocket costs. Both would be capped based on income. This means the tax increases would likely be lower than Sanders plan.

  15. No surprise that Corporate Joe Biden has come out for “saving” ACA. ACA is just a giant subsidy to the Healthcare Industry, which makes Wall Street Happy.

    The idea that we cannot have Universal Health Care or Single Payer health care is bogus. Canada, France, Japan, and Germany among other countries all have some form of Universal Health Care. They also pay less for health care per person and as a percentage of their GDP. Life expectancy in these countries is longer than in the USA.

    H.R.1384 – Medicare for All Act of 2019, now has 117 Co-Sponsors. All four members of “The Squad” are Co-Sponsors.

    Will the Corporations fight Medicare for All Act of 2019?? – Of course they will and they will have their stooges and puppets in the Democratic Party and McMega-Media toss all sorts of road blocks and diversions to stop it. The Republicans who oppose Medicare for All Act of 2019 have No Plan.

  16. Due to my service in Vietnam, I receive care from the VA. It works. Yes, you can find anecdotes of the “horrors of the VA.” Because some have an agenda, and some can’t seem to understand the concept of large numbers. The VA treated some 56 million veterans last year. Out of ANY 56 million iterations, you are going to be able to find a few glitches and problems. But, overall, MY VA care, and my wife’s Medicare, prove to me that universal coverage is the way to go.

  17. It seems that one of our problems with an admittedly very complex issue is that we conflate the health care business and the insurance business. Of course the simplest way to untangle them is to assume that the cost of health care is everything that we, our employers (assuming that if they didn’t provide health care insurance benefits they would spend the same on other compensation) and the government pay for both insurance and non insured health care costs plus some few percents of private health care company “profit” over our whole lives because that is how we pay Medicare and Medicaid for our “old age” health, the most expensive time in life. It amounts to about one dollar of every five that we spend on everything.

    As that’s about twice as much as any other country pays, it is a huge anchor on our ability to compete in international markets (the only markets that there are anymore) in order to pay for everything.

    The truth is that while there are many “tweaks” that could help, the 800 pound gorilla in the room is that we can’t afford all of what is known about maximizing the abilities of everyone to live as long and as productively as possible. We have arrived at the point that we always knew would happen someday where health care rationing is necessary and all of the other countries in the world except us have already processes in place to do that.

    That is a political football, actually one of quite a few, that is beyond our present compromised political ability to address sensibly.

    First we have to restore our political abilities. Then we can figure out how to address all of our growing pile of problems needing attention.

  18. Vernon –
    Vernon —
    The DSM 5 ( Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association) does not recognize the term “Malignant” as part of the PD known as Narcissistic.

  19. Kathy M; The American Psychiatric Association, Principles of Medical Ethics, does not allow diagnosis of public figures to be made public without actual examination or permission to release their medical information; it is called the “Goldwater Rule”. Fact magazine released such information questioning Barry Goldwater’s fitness to be president; he sued and won. This was a good standard to apply to public figures…until we were infected by Donald J. Trump. Perhaps Vernon referred to Trump as the Malignancy; it would certainly fit with the “speculations” of 27 psychiatrists and mental health workers in the book, “The Dangerous Case Of Donald Trump”. We were as a country well aware of his sex, marriages and business life and many law suits for 40 years before his 2016 appointment to the presidency.

    Quotes from the dust cover of the book, “Craig Malkin writes on pathological narcissism and politics as a lethal mix.” Bandy Lee, M.D. states, “His madness is catching, too. From the trauma people have experienced under the Trump administration to the cult-like characteristics of his followers, he has created unprecedented mental health consequences across our nation and beyond.” “It’s not in our heads. It’s in his.”

    And currently, Trump’s malignancy is spreading like a California wildfire. Those who are not his racially infected supporters are stressed to the max and many of us live in fear. There is no doctor’s prescription or health care coverage against his pandemic effect on all of us; those who support his sickness and those who seek a cure. He and his minions are doing their best to deny health care coverage to those most in need.

  20. RN for 20 years who have worked at Riley Hospital for Children where before the ACA–diagnoses like Autism, ADHD were not covered therefore any therapies and medications for these diagnoses were not covered and the parents would have to pay out of pocket for the non-negotiated costs of medications and for a 30 day supply of Abilify at the time was $1000 for 30 tablets. It is now $750 for those who have Humana Medicare and that is the cost to the patient. Thank heavens for GoodRX coupons where the monthly cost can be $22. It was better at that time to have Medicaid and that was after I talked our child psychiatrist into attending the DUR board. I am also proud of two companies losing contracts after the number of complaints I filed on tactics that I felt were discriminiatory and were purposely put in place to make the process so arduous in getting medications and treatments approved and so eventually they had better formularies.

    When I couldn’t get a job for a few years I took what I could get and it was a job with Blue Cross- the entity that ran TennCare for the state. I really do not see and I have never seen the cost savings and believe me at every meeting the focus was on profits, profits. Since they do rake in the profits I also saw alot of waste.

    I was an IU employee and at the time my insurance was great but they also had buying and negotiating power for being one of the largest employers in the state as oppose to small businesses where they have no negotiating powers. I am aware IU’s medical is WAY more after I left.

    Working in geriatric psychiatry and the memory and aging clinic at Vanderbilt I have noted how Mediare will deny almost every thing up front as they know doctor’s offices do not have resources to battle appeals for medications. The hoops that have to be jumped through just to get some basic anti-depressants somebody has been on for 20 years.

    I took some health policy classes at IUPUI in graduate school. The reason why so many doctors are not working in rural parts of our states or not going into certain specialties like geriatric is they can’t afford to do it. They can not afford to work in these places while sitting on 1/2 million dollars in school loans. There is a reason why there are not enough mental health providers, psychiatrists, and a growing shortage in primary care providers. My PCP in Indiana could not afford a nurse because she had to pay the salaries of 5 people whose job was to chase down the money that is owed to the practice.

    EVery day we get faxes in from insurance companies dictating care or offering suggestions. It is unbelieveably obnoxious.

    I just do not believe stake holders should be getting rich off of our healthcare system. Profits should go back into the system and not to Wall Street.

  21. Simply put, the rest of the civilized world has figured out how to provide PROACTIVE health care to its citizens for up to 75% lower costs per capita than our citizens pay into the for-profit health care and insurance system. Biden says our hospitals couldn’t possibly stay in business (the operative word here) with a Medicare for All plan. Really? Then how does everyone else do it?

    The AMA has a union? Who knew? Does that mean doctors don’t think they’re making enough money off of the taxpayer. Beware disinformation.

  22. If other countries can do it, perhaps some of the reasons that we in the USA cannot do it are: we are stupid; we are lazy; we don’t care; it’s too complicated; we make it too complicated…or we are stupid.

    If the VA can do it in spite of a limited number of facilities and an unlimited number of enemies, maybe some of the reasons are listed above in paragraph one. Fact is: the VA system is far superior to Medicare/Medicaid insofar as being a model for a single payer system.

    One thing for certain: we will not solve the healthcare problem by suggesting 100,000-page solutions that drone into eternity on every detail and gag on overbites of perfection. Uncle Sam must get his wanker out of the jaws of the idea that governing–in this case, medical care–has to be done without so much as a loose hangnail side-effect. Treat the patient and deal with side-effects as they arise.

    It’s far simpler than building the Panama Canal or sending humans to the moon and back, neither of which would have gotten far had we demanded a flawless plan before commencing.

  23. Wise comments above.
    Rather than be frustrated and sitting on your hands, why not phone bank for Democratic candidates in swing states, or for Presidential candidates who support Single Payer.
    Change can only come from Congress, so apply your efforts there.

  24. Sheila, you cousin, as always, has sound advice. David Honig makes some good points as well.

    I have had several discussions about single payer/Medicare-for-all with my brother, who is COO of an Accountable Care Organization (ACO) that tries to incentivize Medicare cost reductions (like preventive health care) by sharing a portion of the savings with the physicians. He estimates the true overhead cost of Medicare is in the 8-10% range – still a savings, but not as big as advertised.

    One big point he notes, people are more upset by what they lose than what they don’t have. In the US, we get immediate appointments for hangnail (or whatever). If we really had a sort of national healthcare system (like Europe or Canada), nobody would wait for emergency surgery, but you might need to wait a long time for elective surgery. In the long run, most people would be happy, but the transition would be rough.

    As another suggestion, my thesis advisor opined some 30 years ago that the cost of medical education might lead to a more equitable healthcare system in a different way. Beyond medical school debt, the public pays a large amount of money for the training of what is still a closed profession (the number of medical schools and medical school slots is strictly controlled). He thought that medical students would begin trading years of service in under-served area for debt relief. (I had a friend at the time who joined to navy to have his medical school tuition covered in exchange for four years of service.) At this point, we could have all medical school graduates give a number of years of service like the draft – but no bone spur exemptions – and reduce their medical school costs.

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