091317 Senate Medicare-for-All proposal

Let’s talk about the most recent Medicare-for-All proposal in the Senate. We need hearings, expert witnesses, specifics, and we need to talk through the advantages and disadvantages specifically and with a critical eye, so we get universal coverage as soon as possible.

As a physician, I love the idea of single payer or Medicare-for-all. Everyone would have coverage, so people get care earlier in illness and don’t get so sick, don’t need emergent care as often, and have happier, healthier, longer lives. I would make more money, even at somewhat lower rates per service, because I’m not working for free 20-25% of the time, as I have done much of my career in Texas, and I don’t have to hire a lot of staff to file claims and fight with insurance companies or track down delayed payments. If it’s Medicare Managed Care, then not so good for physicians, because there would still be networks, gatekeeping, lots of claim denials…so how it’s administered matters. I support a non-managed care Medicare system administered centrally without private sector interference. Is that what the current proposal includes?

As a patient, there are some advantages, too, to Medicare-for-All. If I don’t need reproductive health care and some of the more advanced cardiac and newer care/medications, I can get coverage for most things I need, and am free to leave a job and open a business or freelance. But, I’m worried about single payer, too, especially as a patient.

What does it cover? Clearly we have to address abortion and contraception coverage, but there are other problems. Medicare contracts out its coverage decisions to state-level intermediaries, and not every policy about coverage is national. There have been years of problems getting Medicare to cover heart failure treatments like implantable defibrillators, some cancer treatments, and other types of novel and less common treatments that some people really need, and this is a real risk in a federal system, especially with republicans in leadership.

And, there is substantial co-payment and deductible, so much so that many if not most Medicare beneficiaries who don’t qualify for Medicaid buy supplemental policies at substantial cost. Would those still be necessary? Allowed? This is where I wonder if a Medicaid-for-All might be better - Medicaid has no co-pay or deductible. But, many states have Medicaid managed care, and those problems with access to specialists and the hassles of uninterpretable explanations of benefits and other rationing-by-exhaustion schemes that the for-profit companies that administer Medicaid managed care persist, just like they would in Medicare managed care.

And what about those Medicare intermediaries, the ones who adjudicate claims and make some medical policies - many of which are for-profit companies? Do their CEOs still get to make millions at our expense? Do they get to choose not to cover important medical care because they don’t want to, because it might decrease their profits?

We have much to discuss, and reducing this debate to 140 characters is not going to work. We need open minds and hearts, data, and lots of ideas on the table for discussion. Here are some of my ideas:

We need a health care system that:

-covers all reasonably effective and needed care at no co-pay or deductible, and makes preventive care like vaccines and screening tests available at work, school, health centers, at convenient times for people who work and without having to see the doctor in person (preventive care recommendations can be followed like flow charts by anyone - results can go to the physician, but there shouldn’t be barriers to preventive care)

-takes the for-profit hospital and insurance system down and replaces with non-profit entities with strict limits on executive compensation and scrutiny of finances

-controls the pharmaceutical industry so medications are available at reasonable cost to the system

-allows Americans who just cannot stand to have government coverage to pay out of pocket or buy some sort of unregulated insurance, but they must be personally responsible for paying the physician/hospital/etc up front, so we don’t get stuck with the bill if their insurer balks - and this must come with limits on how much of their time physicians, hospitals, and other medical care practitioners can spend on this for-profit/non-governmental sector

-pays for nursing and medical school so our nurses and doctors (and other health care practitioners) don’t graduate with crushing debt, and therefore can have reasonable salaries that fairly compensate for the time and risk they endure and the skills they have (while we’re at it, let’s pay teachers a lot more…) without the costs of care being so high; and, let nurses and other health care practitioners work at the top of their licenses, and let physicians do what we do well, so it’s a system and a team approach and we’re not elbowing each other out of the way

-monitors cost carefully and looks for ways to deliver good-quality care efficiently

-adequately funds medical research and the education and training people need to do it well.