Last Wednesday my wife and I drove down to Boston so that she could do a little holiday shopping with a friend while I saw the nurse practitioner who was going to do my periodic health review and give me a flu shot. Somewhere between New London and Concord on Interstate 89 we passed a Subaru Outback (official pace car of progressive liberals) with a Vermont license tag and a bumper sticker that said “Medicare for all.” The bumper sticker got me thinking about what might be the next chapter in our two step forward and one step backward progress toward universal coverage. Now that Democrats have regained control of the House and are preparing for a serious attempt to win the Senate and regain the presidency in 2020, it is my guess that we will be hearing a lot about “single payer” or “Medicare for all” in the near future. Healthcare was a big issue in the midterm election and will probably be a leading concern again in 2020.
Bernie Sanders made a proposal for “Medicare for all” a big part of his run at the presidency in 2016. His website is still providing the rhetoric that almost won the nomination in 2016.
Americans need a health care system that works for patients and providers. We need to focus our federal investments on training the health care providers. We need to ensure a strong health care workforce in all communities now and in the future. We need to build on the strength of the 50 years of success of the Medicare program. We need a health care system that significantly reduces overhead, administrative costs and complexity. We need a system where all people can get the care they need to maintain and improve their health when they need it regardless of income, age or socioeconomic status. We need a system that works not just for millionaires and billionaires, but for all of us.
If you read to the bottom of his policy statement you see the jaw dropping savings that he argues would accrue to the country, employers, and to individuals along with better care if we could muster the courage to move to a “Medicare for all” healthcare system. His argument is strong because even though the ACA has given millions of people new access to healthcare, there are still almost 30 million people without coverage, and this year it looks like the efforts of the current administration will end up in lowering the number of Americans who buy their health insurance on the exchanges.
Bernie wants to close the gap in one big leap. He does a good job of presenting his argument for the universal coverage and the economies of a single payer system if you are willing to read several hundred words on a website, listen to a Sunday morning news talk show, go to a rally, or look at a YouTube presentation, but in most of those situations he is preaching to the choir. Logical arguments do not make good campaign rhetoric. The idea that your out of pocket expenses for health insurance will go down more than the increase in your taxes requires a combination of trust and an understanding of finance that exceeds the possibilities of an argument that can be made in a thirty second political ad. The sale of “Medicare for all” will take time just as it has taken time for consumer experience to convince a majority of Americans that the ACA is basically something that they should favor because it is an overall benefit even for those who currently get good insurance from their employer.
The situation has changed favorably since 2016. The Republican attempts to repeal the ACA have educated voters to what they have in the ACA and have created a “beachhead” of understanding from which it may be possible to further expand coverage to include many who remain uncovered or for whom coverage is in jeopardy as there are increasing attempts to reduce “entitlement spending” following the new deficits created by the Trump tax cuts for wealthy Americans. Bernie’s numbers make sense to liberal economists and policy wonks but are probably lost on most voters. I was thinking that voters like stories more than political rhetoric, facts, and economic arguments when I opened my local newspaper to the “Opinion” page last Thursday, the day after I saw the bumper sticker, and discovered a short piece entitled “What Healthcare For All Really Looks Like” that was written by Jennifer Yocom of Thetford, Vermont who recently retired after 20 years teaching music in the Thetford schools.
… my husband and I received a call that our son had been in a car accident while visiting his aunt in Northumberland, England, over the Christmas holidays. He had been extracted from the car, flown by helicopter to Newcastle Hospital, and put in an induced coma in the intensive care unit.
After a nail-biting flight .., I arrived to find my son cheerful and glad to see me, though he had no idea why he was in the hospital…I asked the nurses and doctors to let me take him home to my sister’s home to recuperate. They wouldn’t let me, so I moved into the hospital to be with him.
He ended up staying in the hospital for 10 days. Helicopter transport, ICU, induced coma, private room, MRI. No one asked if I had insurance; no one asked me to pay one cent…
Jump ahead 10 years. I returned to Northumberland in late March to be with my sister, who had just received a diagnosis of acute myeloid leukemia with a bleak prognosis…Hospice and the MacMillan nurses (extra care for cancer patients) came to the house to make arrangements for care; the village nurse and doctor came to the house numerous times to check on her, though she was completely mobile; a team of two nurses came to her home multiple times as her condition worsened; a pharmacist was called at his home on a Sunday and he delivered a medication a couple of hours later; and finally two nurses came that night to verify her death. And here’s the thing — no one asked for a penny.
Yes, my sister’s taxes were high, but as I walked around the ancient and picturesque town of Hexham, the streets were full of healthy, energetic, white-haired senior citizens. You see, people there don’t have to worry about health care. It’s true that for some non-emergency surgeries, there may be a longer wait than we’re used to. But, oh my gosh, imagine not having to worry about choosing between paying for your health care or paying for rent or food or car payments or child care or anything.
Now, please understand that I am not any kind of expert on health care, taxes or insurance. I’m a mom and a sister who unwittingly witnessed what a health care-for-all policy looks like. Both experiences were traumatic and emotional. Not having to worry about expenses left me with the time to give my full attention to my son and my sister.
I don’t know about you, but I’ve paid thousands of dollars over the years to insurance companies. I’d rather pay taxes.
Mrs. Yocum’s testimony would probably win more voters over to the idea of a single payer than all the Powerpoint presentations that you or I might attentively attend. She speaks to a quality of care that is rare even if you can afford a “platinum” plan from Blue Cross. The story would not be possible if there were not a societal consensus in the United Kingdom that healthcare is a right, not a privilege, that is extended to anyone: native, immigrant, or traveler passing through their land.
I sometimes think that interesting ideas come in packages of three. Yesterday I was in a group conversation about the “Beatitudes.” Another person in the discussion group brought up a concept from Jewish religious literature about the pursuit of perfection:
It is not incumbent upon you to complete the work, but neither are you at liberty to desist from it.
The pursuit of the Triple Aim, sustainable, high quality universal coverage, has turned out to be an enormously difficult endeavor. It did not happen during the forty plus years of my career even though there have been people earnestly pursuing it for the last century. I have no idea if it will occur before my time on earth is over, but the fact that it can’t be accomplished easily, or perhaps within our professional or physical lifetimes, does not excuse us from the moral responsibility of continuing to work for the moment when the sum total of effort, experience, and enlightenment will make it a reality.
As I think about the history of healthcare reform and the multiple failed attempts and the partial successes of Medicare, Medicaid, CHIP, and the ACA, I doubt that we will jump from where we are to “Medicare for all.” There are several things that are still barriers to overcome. The first and probably most difficult barrier to overcome is the underlying distrust that many Americans have of the government. The second reality is that our healthcare system is a collection of privately owned assets that will remain privately owned for the foreseeable future. Another issue is that there continues to be great variation from state to state because Medicaid is a collection of state managed programs with shared finance between the individual states and the federal government. Our finance system may be a public/private partnership, but the institutions that deliver care would probably not joyfully embrace having the government be their only source of payment. Atul Gawande predicted that the evolution of healthcare will be “path dependent,” and our path is through private institutions in what we hope will be a competitive market place. The ACA was built to those specifications.
An intermediate step between where we are and “Medicare for all” is a “public option” on the exchanges. The ACA almost included a public option.The public option is an idea that first surfaced in California in 2001. During the 2008 Democratic primary process John Edwards, Hillary Clinton, and Barack Obama embraced the idea with some variation. President Obama did want to include a public option in the ACA and it was in the bill passed by the House, but Senator Joe Lieberman and a few others killed it in the Senate. As a result of the compromises that occurred in the Senate the public option was not part of the final version of the ACA that was passed by the “reconciliation process” that requires a simple majority after the Democrats lost their ability to overcome a filibuster when they dropped to fifty nine votes after Scott Brown, a Republican, was elected to complete Ted Kennedy’s term after his death.
The time may be ripe for the public option. There are two public option bills being offered by Democratic Senators. One plan offered by Senators Michael Bennet of Colorado and Tim Kaine of Virginia would be phased in between 2020 and 2024 and eventually be offered on the public exchanges and to employers. The other plan is offered by Senators Chris Murphy of Connecticut and Jeff Merkley of Oregon and would move much faster. In reality either approach could be a stepping stone to “Medicare for all” and both would offer opportunities to reduce drug and administrative costs. Much of the resistance in the past has come from commercial insurers. They do not relish the idea of competing on price with the low overhead of a government program.
Time will tell, but what I am sure of is that things will change. The public is gradually figuring out that healthcare is a critical necessity for everyone. We will all be better off when we figure out how to do what most of the developed world has been doing for sometime. In the interim it is good to remember the Jewish wisdom that we may not complete the work soon, but we must keep trying.
