By Jennifer S. Bard
Just as medical students find themselves being asked at parties to look at rashes, this year health law students (and professors) are being asked about the proposals to fix our broken health care system being offered by the many candidates vying for the Democratic Party’s nomination for president. Talk about these issues are certain to continue through the primaries as 81% of Democrats agree that “the federal government has a responsibility to make sure all Americans have health coverage.” While Republicans are less sure about who should pay, health care remains a top issue for 69% of the electorate.
So long as there is no specific health care plan to evaluate, the public discourse is likely to include considerable fear mongering and confusion. Change is scary. But there are things we can know. First, the vast majority of Americans like the coverage and quality of care they are getting. However, 79% of all Americans are dissatisfied with health care costs and most of those polled by the Kaiser Family Foundation want to expand access to health care, even if they can’t agree on a method for doing that.
The central divide among the candidates is whether they do, or do not, support expanding the two existing (civilian) programs: Medicare and Medicaid. Most notably, Elizabeth Warren and Bernie Sanders are all in for what they usually call “Medicare-for-all” and Joe Biden is still carrying the torch for expansion of Medicaid initiated by Obamacare. This plan is essentially “Medicaid for All Who Need it.” Critical to understanding all of these proposals, and the many arguments against them, is understanding two very different programs with unfortunately very similar names.
Within the constraints of a blog post, here are some answers to the FAQs we all get and some sources of reliable information. Hopefully, this information can help people understand the programs, as well as some of the benefits and consequences of expanding them beyond those currently lucky enough be eligible for them today.
What are these programs?
Medicare, a taxpayer-funded insurance program administered by the federal government, covers all U.S. citizens 65 and over, whether they need it or not.
Medicaid is run as a partnership between the federal government and individual states. States have discretion about whom they cover beyond a core population of low income pregnant women and children.
Both programs work together to cover health care costs for people of all ages with disabilities.
Medicare and Medicaid are public insurance programs that, like private insurance programs such as Aetna or Cigna, pay medical bills but do not employ doctors or run hospitals. Unlike the private companies, though, they operate very efficiently with administrative costs hovering around 3%, which is far lower than the 15-20% overhead of private insurance companies.
Surveys indicate that people eligible for Medicare, Medicaid, or military programs are the most satisfied of anyone with their health care (Medicaid, Medicare). Medicaid and Medicare provide high quality care (Medicaid, Medicare) and people whose health care is funded by these programs receive results the same or better than those covered by private insurance.
What’s the controversy?
If people who already use these programs like them so much, why is expansion so controversial? Fear of the unknown. Without any one specific proposal to evaluate, people are left to speculate what they will experience and how much it will cost. They are also vulnerable to the scare tactics used by insurance companies that are likely to be the big losers if more people, let alone all people, are insured by the government. In terms of quality of care, it’s unlikely that anyone will notice any difference in quality or character of care.
There are no “Medicare doctors” or “Medicaid hospitals” beyond the reality that some conditions are more common among the old than the young. There are many plausible reasons why care might be even better.
Fewer companies means less paperwork, bringing an end to the hours doctors now spend trying to meet the criteria of and getting approval from multiple insurance companies.
But many candidates seem confident in scaring us about the “dangers” of relying on the kind of public/private partnership health system so beloved in dozens of countries. We spend more and get worse results than any country to which we would want to compare ourselves. Do we think the that the European, Canadian, Australian, South American, and Asian families talking on iPhones, watching Netflix, and flocking to Disney World would tolerate, let alone extoll, a health care system if they could not access fast and appropriate care for the kinds of health concerns shared by all humans such as broken bones, high blood pressure, asthma, and itchy rashes let alone cancer, heart diseases, or kidney failure?
What’s the cost?
Some have argued that a single payer system would end health care as we know it because it would become more expensive for doctors and hospitals to operate. These arguments would be more plausible if they were not made any time anyone proposes changing the current system. The scary “Harry and Louise” political ads in the 1980’s responded to the prospects of managed care, which has become so embedded in our current care that is has become invisible.
Certainly, it would cost the government more than it does now if it takes on the responsibility for insuring more people, but how much more really depends on how it happens. Even if taxes went up, the cost of health care for individuals could easily stay the same or go down.
For many people, what they actually pay for health care beyond co-payments is something of a mystery. Everyone who gets health care through work is essentially already paying for it through lower wages. Also, much the current cost of health care comes from rising prices, at least some of which is attributable to having a chaotic system.
Private health insurance is extraordinarily profitable in the United States in large part because it is highly selective. It only covers those healthy enough to work and has no longer term responsibility for anyone.
Medicare-for-all would also eliminate the instability of our current system, which is dependent on continuous employment. Employers can change health insurance companies even more frequently than employees lose or change jobs. While insurers and pharmaceutical companies could all face lost profits in a single payer system, it’s not clear what if any loss there would be to individuals.
The challenge of developing a health care system that provides access to health care for all our citizens is not unique or insurmountable. The U.S. spends more for worse results than many other industrialized nations.
On top of that, private health insurance companies do not have to cover anyone over 65. The system has become so tangled and complex that it’s hard to develop a clean analogy, but it’s somewhat as if car insurance companies charged all drivers top dollar but only paid the claims of 35-56-year-old women driving Volvos and Subarus.
Where can I learn more?
As usual, the Kaiser Family Foundation (KFF) is the go-to source for non-partisan and clearly presented facts. In a series of issue briefs KFF provides an overview of key issues surrounding Medicare-for-all and public buy-in proposals. More recently, KFF conducted this analysis of 324 studies of the impact of state Medicaid expansion. The organization also provides updates in Kaiser Health News where Julie Rovner and her team report on the latest plans and proposals. Every Friday they gather with the top health policy reporters to review the week in their What’s the Health podcast.
For background on reporting on health care and research briefs on health care policy topics, another reliable source is Journalist’s Resource, a project of the Shorenstein Center on Media, Politics and Public Policy at Harvard’s Kennedy School of Government.
HealthAffairs publishes many of the most respected legal and health policy researchers. The Pew Charitable Trust, the Congressional Budget Office, and the Centers for Medicare and Medicaid Services also provide important information and conduct research on Medicare and Medicaid policy.
Both the CATO and Heritage Foundation provide excellent background information about health finance policy, but know that they do so based on pre-existing views on what government should and should not pay for.
It’s appropriate for candidates to propose new programs and criticize old ones, but let’s not let the realities of Medicaid and Medicare get lost in campaign rhetoric.
