'Medicare for All': Finally Prioritizing Patients?

Experts at a House hearing take sides on a single-payer system.

This article was first published on Wednesday, December 11, 2019 in MedPage Today.

By Shannon Firth, Washington Correspondent.

WASHINGTON -- Expert witnesses at a House Energy & Commerce subcommittee hearing Tuesday offered the pros and cons of single-payer healthcare systems.

"Every day, nurses witness the failure of our current health system," said Jean Ross, RN, president of National Nurses United. She reported that one patient arrived in the emergency department (ED) in a "hypertensive crisis" at risk of an "imminent stroke." The patient reported that he took his blood pressure medication every other day, instead of daily, because of its cost.

She also shared that her grandson, Evan, had been sick as an infant. Her daughter was worried she would not be able to afford the co-pay, Ross said, so she covered the cost. If Ross had not done that, her grandson may have never received care, she added. In the ED, Evan was diagnosed with encephalitis, a condition that can cause permanent brain damage and even be fatal, she said.

Without care, Evan would have "been in severe trouble," Ross said. "Single-payer 'Medicare for All' is the only way we can guarantee healthcare, while also reducing the amount of money we spend on healthcare overall," she said.

But others disagreed, pointing out that a single-payer system would lead to "serious trade-offs," including the potential for rationed care.

Universal Coverage?

In the U.S. today, 30 million people are uninsured and 44 million others are considered under-insured. Despite paying more than other countries for healthcare, the U.S. ranks lower than many developed countries on health indicators including average life expectancy, maternal mortality, infant mortality, and death from preventable diseases, Ross said.

"Under 'Medicare for All,' we will transform our profit-driven ... insurance system into a healthcare system, one that prioritizes patient care," she said. Ross explained that because insurance carriers will no longer have a say in treatment options, doctors and nurses will provide care based on their professional judgment, and patient outcomes will improve.

She urged all members of Congress to support Rep. Pramila Jayapal's (D-Wash.) "Medicare for All Act of 2019." It is the only bill that would provide healthcare to everyone in the country "regardless of their ability to pay," Ross noted.

Jayapal's proposal was one of many bills designed to expand access to healthcare. Rep. Rosa DeLauro (D-Conn.), Rep. Antonio Delgado (D-N.Y.), Rep. Brian Higgins (D- N.Y.), and Rep. Tom Malinowski (D-N.J.) also put forth proposals at the hearing.

The "Medicare for All Act of 2019" would eliminate copays, deductibles, and out-of-pocket expenses, as well as employer-sponsored insurance. It would also offer additional benefits over current Medicare plans including dental, vision, and hearing (the bill was the subject of a separate House hearing in May).

DeLauro's bill would maintain access to "high quality" employer-sponsored health plans, if employers choose to offer them, and would automatically shift everyone enrolled in the Affordable Care Act (ACA) exchanges, Medicaid, or the Children's Health Insurance Program (CHIP) into the proposed "Medicare for America" program.

Higgins' bill would allow people, ages 50-64, to buy into the Medicare program. Malinowski's bill would allow first responders, including law enforcement officers, firefighters, and those providing emergency medical services (ages 50-64) who are "separated from service due to retirement or disability" to buy into the Medicare program. Delgado's bill would create a public option for anyone who is uninsured or "unhappy" with their current health plan.

'To What End?'

Doug Holtz-Eakin, PhD, president of the American Action Forum, a conservative think tank here, described universal coverage as "a very important goal" and Jayapal's bill as "a truly sweeping reform."

He differentiated it from other single-payer plans that don't ban private insurance, don't eliminate the role of the states or regents, nor do they eliminate co-pays or other incentives for encouraging efficient utilization of care.

"This is like nothing else that has ever been proposed," Holtz-Eakin said, but cautioned that it would have "serious trade-offs."

For instance, the lower rates of reimbursement that could be imposed under such a plan -- at or near Medicare rates -- would "inevitably deteriorate" the quality of hospital care. In extreme cases, some hospitals might close, which obviously undermines the goal of increasing access to care, he stated.

Holtz-Eakin estimated a "ballpark" $30 trillion price-tag over a decade for 'Medicare for All.' If financed in the usual manner for Medicare, it would require a 21 percentage point increase in the payroll tax, according to research from the Heritage Foundation, leaving two-thirds of American households "worse-off" financially.

"And to what end?" he said.

Half of the roughly 30 million people who are uninsured now are eligible for public programs such as plans on the ACA exchanges, Medicaid program, or CHIP, Holtz-Eakin said. Others have rejected the offer of employer-sponsored insurance, he claimed.

After the hearing, Holtz-Eakin told MedPage Today that 4.7 million people could enroll in a "zero-premium bronze plan" on the ACA exchanges and "simply don't do it," according to a study from the Kaiser Family Foundation.

The only people who would likely benefit from a single-payer plan would be the 2.5 million "relatively low-income" individuals living in states that didn't expand Medicaid. "Is it worth overturning the enormous heterogeneity and rich complexity of the U.S. healthcare system for 2.5 million individuals?" Holtz-Eakin said.

He also said he did not support more "targeted" approaches, such as Higgins' Medicare buy-in, saying it would only cover about 500,000 people even with $180 billion of additional money.

'Only the Poor...'

Another criticism of a single-payer system is that it would lead to restrictions in access to care.

Scott Atlas, MD, senior fellow at the Hoover Institution, another conservative think tank, said that cancer drugs are far less available in single payer countries like Canada and Britain. He also cited wait times of 8 months for brain surgery in Canada.

Half of all residents of England who earn more than 50,000 pounds buy private insurance, Atlas said.

He claimed that "only the poor and lower-middle class are stuck with nationalized, single payer healthcare, because only they ... cannot afford to circumvent the system."

But Ross rejected Atlas' comments about rationed care, saying that there's "self-rationing now." She told MedPage Today that those with high co-pays or high deductibles often don't seek care even when they need it.

As for the concern that 'Medicare for All' would lead to two tracks of care -- one for the wealthy and another for the poor -- Ross said that is already happening now under the current system.

The current healthcare system "is for the wealthy ... and statistics show that," she said. "The more money you make, the better access you have to healthcare, the better you do ... We want to fix that. Nurses want everyone to get the same quality care across the country."

She stressed that 'Medicare for All' "is not socialism ... [and] the delivery of care is just what you're used to. It would be private, but it would be publicly funded."

As for upending the healthcare system Ross argued that the government already funds at least two-thirds of the healthcare system; all that's needed is to redirect the remaining one-third back into the government.

"It's not taking apart the system. It's building on what we've already got," she said.

Regarding the cost of single payer plans, she said it was "disingenuous" for witnesses to underscore that point, without also noting the potential savings.

"We can't afford the system that we have now." Ross said.