The Medicare-for-All Debate Causes Confusion and Stress
Can’t We Get Some Reliable Data?
There is much bemoaning these days about the supposed inability of people to incorporate facts into their beliefs about politics, science, and health. We hear a great deal about confirmation bias and motivated reasoning as the basis behind our constitutive inability to accept the facts.
While cognitive biases certainly make it difficult for us to accept data when we form beliefs and make decisions, that still does not mean that facts are unimportant. When it comes to healthcare reform, however, it seems nearly impossible to get even the most basic facts that might help us make informed policy decisions. The resulting confusion is the cause in some of us of profound anxiety and even despair.
There are two things about the American healthcare system that seem universally agreed upon: we spend more money per person than any other high-income country and we have the shortest lifespans. Those facts should surely merit a serious effort at reforming how we deliver healthcare in the United States.
What has cropped up on the political scene, however, is a contentious debate about whether or not we would be better off with a single payer, national healthcare system similar to that employed in every other developed country. Some have called the proposed plan for universal health care “Medicare for All,” while others use the derisive term “socialized medicine.” For some of us, this debate might even produce things that can require healthcare interventions, like anxiety and depression. The debate is confusing and almost entirely devoid of facts we can get our arms around and believe in. In our effort to promote the use of scientific evidence in public policymaking, we are often shocked by the inability of people discussing healthcare to be able to give us anything like reliable data.
The Things We Want to Know
Here are some of our questions about our current healthcare system and proposed reforms that we believe should be answerable with reliable information:
· What are the things we spend more money on than countries that do have national healthcare systems? Is it on drugs, doctors’ fees, hospital bills, advanced laboratory and imaging studies, administrative costs, or some combination of these? It turns out that the conditions that generate the largest share of healthcare spending in the U.S. are not life-threatening conditions like cancer or coronary artery disease but neck and back pain and other musculoskeletal disorders. According to the federal Centers for Medicare and Medicaid Services (CMS), the U.S. spent $3.6 trillion or $11,172 per person on healthcare in 2018. By contrast, the United Kingdom spends about half as much as we do on healthcare. To be told that the reasons for this difference are complex is unhelpful. We are sure there are many complex factors that go into how much a country spends on healthcare, but it should not be that hard to give the public the sources of the huge difference in spending on healthcare between us and the rest of the developed world in terms that are understandable. In other words, can someone please explain to us what is it that we spend all the extra money on and is it necessary that we do so?
· How much do the things we are paying for actually cost? It seems almost impossible to get even the most basic information on how much things cost in the U.S. healthcare system. If you have a headache and the doctor orders an MRI of your head, how much does the MRI cost? Most likely no one will be able to tell you, not the doctor, your health insurance company, or the facility that actually does the MRI. About to have a baby? If you have, like most women, an uncomplicated labor and delivery, ou’ll get a bill from the hospital where you deliver but try to find out how much that bill will be beforehand and you’ll just get frustrated. When the government recently proposed a new rule ordering hospitals and health insurance companies to be transparent about their prices, they recoiled in horror, claiming to do so would cost billions and just confuse the public. And when you get the bill for medical services, chances are you won’t be able to understand it, leading two Johns Hopkins physicians to recently propose in the Journal of the American Medical Association (JAMA Network) that the quality of bills sent to patients should become the subject of metrics upon which hospitals are judged, just as they are for things like the number of surgical infections they have annually and how many people survive ICU care. “The financial harm of medical care should not be separated from the clinical consequences of care, because both outcomes can have a major influence on the health and well-being of patients,” they wrote. Of even more concern than the quality of bills is the fact that many people who do have health insurance still cannot afford to get the care they need According to one recent study, “In 2017 nearly one-fifth of individuals with any chronic condition (diabetes, obesity, or cardiovascular disease) said they were unable to see a physician owing to cost.”
· Why don’t we have better health outcomes if we are spending so much extra money? The current life expectancy in the U.S. is 78. 6 years, compared to an average of 82.3 in 12 high-income countries. Life expectancy in the U.K. is 81.3 years and in Canada it is 82.0 years. Once again, there is no doubt that the reasons for this difference are complicated. And of course, life expectancy is not the only way to measure the success or lack thereof of a healthcare system. But critics of national healthcare systems in other countries often insist they don’t deliver the same high quality of care as we get in the U.S. They point, for example, to allegedly long waits for some medical procedures, like gallbladder removal and spine surgery. It is unclear that this claim about longer waiting times for national healthcare systems is actually true. Isn’t it possible, however, to give us some real, objective sense about whether the quality of care in national health care systems is indeed better, equal to, or worse than the system we have in the U.S.?
· How much would it cost the U.S. to convert to a single payer, national healthcare system? Here, we get a lot of numbers, none of which make much sense. One number that is often cited is that Medicare-for-all would cost the United States $32 trillion. But that number turns out to be over ten years and includes increased U.S. government commitments. Now, it is hard to figure out how much of that average $3.2 trillion per year spending would replace what we are already now spending on healthcare (remember that $3.6 trillion annual healthcare spend figure above). How much would be offset by the profits made by the health insurance industry, which amounted to $35 billion in 2019. And if taxes must be raised on middle-class taxpayers to help fund the national healthcare system, how much of that would be offset by people no longer paying premiums to the health insurance companies, either directly or through salary taken out of their paychecks? In order to afford the ever-increasing cost of health insurance, employers have increasingly adopted plans that include higher co-pays and deductibles for their employees and that have narrow networks of providers, leaving many visits to doctors completely uncovered. Would a universal healthcare system reduce the burden of premiums, high copays, and large deductibles for working people? It might even result in higher wages, because higher premiums in employer-based health insurance plans are said by some economists to drive wages down.
· Is it true that most people like their current health insurance? That is certainly a consistent finding when surveys are conducted. But who are these people? Right now, 44 million people are enrolled in Medicare, 64.5 million Americans are covered by Medicaid, and 9 million veterans are enrolled in the Veterans Administration’s health care system. Altogether, then, 117.5 million Americans are covered by government-sponsored, single payer health care systems. That’s more than a third of the US population. A recent RAND Corporation study showed that Medicare beneficiaries “see the largest return on the money they pay for their healthcare,” whereas people with employer-sponsored plans “see the least amount of value.” We can also ask the question, how many of the people who say they like their health insurance have actually ever used it for more than the occasional doctor’s office visit or antibiotic prescription? Complaints may be more frequent among people who have had more significant medical bills and found themselves drowning in paperwork and responsible for thousands of dollars in co-pays, deductibles, and out-of-network costs. As noted above, increases in deductibles and copays are increasing the number of people who have health insurance but still cannot afford to see a doctor. In fact, a recent poll showed that nearly one third of likely voters “are very or moderately worried about being able to afford their health insurance...and out-of-pocket costs for prescription drugs…”Then there are the 27.5 million Americans who have no health insurance at all. They were probably not asked if they are happy with the situation.
People running for public office will, of course, be very willing to answer these questions. Some will tell us that national healthcare is unaffordable in this country and that the only way other countries afford it is by restricting care below acceptable standards. Others will tell us that national healthcare will actually save us money, as a study by Yale University investigators published in The Lancet showed.
It should be possible for us to get objective and understandable answers to the questions we have posed. If the federal government can’t do it for political reasons, then let’s figure out which non-governmental agencies we trust to analyze the data and explain them to us. If a universal healthcare system really would result in massive debt and poor healthcare, then of course we would reject it. If it would instead decrease total healthcare spending and result in everyone having insurance and better overall outcomes, we would demand it. The current information situation seems only designed to make us feel anxious and threatened. We are being frightened by a myriad of statistics that threaten us with catastrophes—losing our healthcare coverage, having to pay exorbitant taxes, and getting second-rate care. We know that many other high-income countries have somehow been able to provide universal healthcare and that it is cheaper and associated with longer life than our system. What we have a right to insist on is that we get a clear and unbiased explanation of why the United States has (or doesn’t have) a unique situation such that what works in the UK, France, and Germany cannot possibly work here.
As much as we dislike making arguments on the basis of anecdotes, we could not resist mentioning this one, most but not all of which we were able to verify from news reports : recently we heard about a 43-year old woman who was attacked in the Bronx, NY and severely beaten. A few days later she went to a local hospital complaining of leg pain and was told she needed immediate hospital admission and treatment, but she feared getting hospital bills she wouldn’t be able to afford and decided instead to go home. She died a few days later when a blood clot in her leg embolized her lung. Obviously, nobody should refuse emergency medical care because they are afraid about how much it will cost, but we suspect that in our dysfunctional healthcare environment this is not an isolated example. All we are asking for is a straightforward, data-driven, and politics-free answer to basic questions about our healthcare economy. It’s time to stop confusing and stressing us with vague answers and inexact statistics.