What are the arguments against Medicare for all?

Great Debates
421

…nope.

Your anecdote does not mean as much as mine.

My neighbor gets the same level of healthcare that I got at exactly the same cost. The guy down the street gets the same level of care. The person who is unemployed is entitled to the exact same level of healthcare as the CEO of the biggest company in the country.

Because our system is universal. My anecdote accurately portrays what every person in this country gets from our healthcare system.

Your anecdote does not do this. Your anecdote does not give me any insight into how much people in America have to pay in order to access healthcare. I know from statistics that you already pay a bigger percentage of money on healthcare than I do even before we get to your insurance. So you pay your taxes. Then your premiums. Then your copays.

Your anecdote tells me about you. But it doesn’t tell me about the person on minimum wage, or the person who doesn’t have a job.

Here’s what you simply aren’t getting: universal healthcare is universal. Everybody gets it. Everybody.

There is no 2-3% of people that maybe won’t or can’t get coverage. That isn’t how it works.

Is that something you think will last forever? How do you expect to make your 'tweaks" if the Dems never get any leverage ever again?

Lets forget about the “stop making deals” part for a minute and address the “trying to please Republicans” bit instead. If the Dems get back into power: do you think they should continue with the system of “trying to please Republicans”? Do you think that was a smart part of being in government? Did it work?

The Netherlands and Switzerland don’t have to deal with “State rights.” The “mandatory basic coverage” is actual real basic coverage and not the ridiculous levels offered in the United States. And they still pay half as much as you do now and would nothing would change with just a few “tweaks.”

Easier to implement means easier to repeal.

You haven’t shown a path to UHC via the ACA. You’ve simply waved your hand.

422

Thank you for so vividly demonstrating zero understanding of the issues being discussed here. Instead of answering the important foundational questions I asked in post #416, you point me to a naively simplistic definition of what “single payer” is supposed to mean, to wit, that there is presumed to be just one payer – something that most of us can trivially figure out for ourselves. But that has nothing to do with the real issue. There are in fact multiple payers in Medicare, because there is the government, there are private insurers involved either in terms of additional coverages or in Medicare Advantage, and there is lots of personal money involved because Medicare is so fundamentally inadequate – so much so that it’s been estimated a retired person would need about a quarter of a million dollars in savings just to ensure decent health care in today’s America. Which facts bring us closer to the crux of the issue.

Because the point, you see, is not in debating silly semantics, but in the substantive meaningful debate over whether a particular solution will really solve basic structural problems – the fact that “single payer” functionally means the things I mentioned in that post you completely ignored: the ability to have uniform costs across the board, to control those costs, to provide unconditionally guaranteed universal access to all medical services, and to have a common community-rated system paying into the universal fund. Single-payer systems such as in Canada have those features, and so do technically multi-payer systems like in Germany, because the multiple payers of the public system there are all coordinated, and are tightly regulated in the public interest. The US system was – and would remain under “Medicare for all” – a free-market catastrophe in which nothing is coordinated.

If you can credibly explain how your ridiculous scheme can achieve those objectives – like costs in line with the rest of the world and guaranteed universal access – I’ll be happy to listen and acknowledge you were right. Absent such credible explanation, I will continue to assume you have the peculiar US-centric blindness to the fundamental values that define health care policy in the civilized world.

423

Two of the other major players are Medicaid (particularly for nursing homes) and the VA.

424

If you define “waving of hands” as providing specific examples of countries that have used ACA-like framework to get UHC, and specifics of how it can be done here, all while you pretend otherwise, then yeah, it’s “waving of hands”.

As this point, the only thing stopping UHC is political, not technical. There’s no reason that the ACA can’t technically get us to full coverage.

The only “waving of hands” are your transformational ideas on changing our politics. It’s nothing more than “wave hands, stomp feet, yell at the top of our lungs, and everything will be better” type suggestions.

425

Medicare is single-payer for the over 65 population in the US. If you don’t like Medicare, or have issues with it, or have suggestions on how to improve Medicare, that’s fine. I’m no huge fan of it myself. But it is single-payer.

426

…LOL.

Other countries did not use the ACA-like framework to get to UHC.

Other countries developed UHC using systems that best fit the goals and the outcomes for the country.

For goodness sakes get it right. America tried to adopt the framework used by a couple of other countries to get to UHC. Not the other way around.

I’m not pretending. There are significant differences. And no amount of hand-waving from you will dismiss those differences.

Its both.

Except you have conceded that it won’t get you to full coverage. You state 2-3% of people won’t be covered.

Are we going to do this again?

You can’t just delete my questions to you and pretend that they don’t exist. “Stop trying to please Republicans” is a simple transformational idea. Its an idea that is embraced by the Republican party: they don’t try to please the Democrats at all. Can the Dems embrace the same policy? Should they? Yes or no?

427

Full coverage is only one of the problems the U.S. faces. The other major problems are the very high cost and low quality: the U.S. costs about 18% of GDP compared to about 10% for comparable Western European countries yet quality wise the U.S. is near the bottom for many health measures for these comparable countries. ACA won’t help with these, while single payer will (all we have to do is copy what these other countries are doing).

As to risk from the politicians, note that there was negative reactive from lots of Republicans to both Social Security and Medicare when enacted. But you see very few Republicans calling for shutting these programs down (because they are so broad it would be political suicide). You do see Republicans calling for shutting down ACA because only a minority get coverage from it. Medicare for all would have the same broad support–just like none of the Conservatives in Britain talk about demolishing their National Health Service even thought it is “socialized medicine”.

428

What’s the mechanism for reducing expenditures by 45%?

429

General answer: (a) through government regulation of provider fees, so that regardless of whether there is one payer or many, fees for medical services are transparent and uniform for all providers; (b) by regulating insurers (if there is more than one) so that all coverages for medically necessary services are essentially identical, and then (c) leveraging these efficiencies to establish lower fees comparable to other countries where insurance overhead and non-payments are no longer factors that have to be figured into medical fees. Providers are generally willing to accept lower fees knowing they will be automatically paid in full by EFT rather than spending weeks or months fighting with insurance companies and drowning in paperwork.

This is essentially how it works in Canada. Provider fees are set by negotiation between each province’s health ministry and the province’s medical association representing the doctors. It’s a collaborative negotiation but ultimately it’s the government’s authority as the single payer that enforces it. It’s a philosophically different approach – as it is in most other countries – where health care is treated as a public service rather than a commercial industry, even though medical providers themselves are often entrepreneurial and for-profit (except that full-service hospitals are usually non-profits).

Government regulation is therefore considered necessary to ensure that public service goals are met, including cost control. How about providers who won’t accept the fee and bill extra? Provinces accepting federal health care funds cannot allow extra-billing; that is, the agreed single-payer fee must be accepted as full payment. From the link above:
The Canada Health Act also contains provisions that ban extra-billing and user charges:

[ul]
[li]no extra-billing by medical practitioners or dentists for insured health services under the terms of the health care insurance plan of the province or territory;[/li][/ul]
[ul]
[li]no user charges for insured health services by hospitals or other providers under the terms of the health care insurance plan of the province or territory.[/li][/ul]
How about providers who opt out altogether? There is nothing to opt out to, because private insurers are not permitted to make a business of insuring medically necessary services, only supplemental ones.

This explains not only cost control, but also the universality, and also explains why there is strong impetus to maintain the quality of the system and why there is little risk of political meddling: this is the system that everyone uses, that the politicians’ constituents all use, and that the politicians themselves and their families use.

I trust this also helps explain what is truly meant by “single payer”. There are variations in other countries, where “single payer” might be replaced by “a common set of regulated rates and guaranteed coverages”, but the philosophical dedication to the social principle of health care as a public service remains the same.

430

1783:

Founding Father #1: We need to limit this new government. Any ideas?

Founding Father #2: Keep it de-centralized! The Articles of Confederation are working just fine. There is no way to limit a potential government of such massive size and scope without regular bloodshed.

Founding Father #3: blows smoke What if we…like…get a piece of paper, right? And we can write down…like…instructions, man…on how the government should limit itself! There’s no way anybody would ever NOT follow those instructions, bro!

431

Yes, keep pretending.

432

I no more want Medicare for all than I want everybody to go a sushi restaurant that is really expensive and serves spoiled fish.

433

Wow, that’s going real far back. We have textualisits, who feel the text should be interpreted as written, and originalists, who feel that the text should be interpreted as it would have been at that time, and we have living consituionanalists, who believe that the constituion should be interpreted with the intervening 200 years of legislation and culture as relevant.

Then we have this, which interprets the constitution as the pipe dream of some stoners.

434

So we’re going to legislate it away? The same body that, for years - no decades, has been trumpeting the out-year savings from reducing waste and fraud in the Medicare system is going to somehow cut everything by 50%. You’ll have to excuse my skepticism.

I guess I’ll provide my argument against Medicare for all. I don’t believe the objectives will be met. I believe we’ll wind up with a massive entitlement that will do what every other government provided entitlement does - grow and not deliver on its raisons d’être (or, perhaps more accurately, redefine itself so its raisons d’être become whatever it’s doing).

I don’t believe we can change what we spend substantively and I haven’t heard a good reason to try to do something that drastic.

I’m all for attempting to take parts of what is rolled up in ACA and turn them into government programs (most notably, some sort of support for pre-existing conditions). If they were government programs, we could but a price tag on it and decide. With ACA, we’ve buried the price tag in private insurance premiums and the politicians can tell us it’s the nasty insurance industry doing this to us.

Oh, and this:

435

I agree with you about Medicare, and that’s precisely the point I’ve been trying to make many times right in this thread. Both Medicare and the ACA – but especially the latter, and especially in the absence of the originally proposed public option – are solutions that were highly compromised in order to force-fit them into a health care system completely dominated by private insurers, in which costs continue to spiral out of control and quality is determined solely by one’s financial means. I totally share your skepticism that a few tweaks are not going to do anything to bring the US system even remotely close to the UHC systems in other countries, either in overall quality, universality of access, or ability to control costs.

And it’s only getting worse. One of my relatives in the US just lost his excellent long-time family doctor, because the doctor, frustrated with insurance bureaucracy, joined a boutique concierge service where it would now cost nearly ten thousand dollars a year just to belong to this exclusive “club” where, for a fee, doctors now have the time to give attentive service and priority access to the best medical specialists to those who can afford it – some of these concierge services charge as much as $40K a year for membership. Instead of being regarded as an essential public service as it is in other countries, health care in the US is responding to cost and resource challenges by becoming more mercenary, exclusive, and money-driven than ever.

The good reason to do something “that drastic” is that this is the level of structural change that’s required in order for the thing to work as well as it does in other countries. It doesn’t HAVE TO be single-payer, though it may as well be – a single payer in each state, working under common federal guidelines in return for federal health funding. But it could also use the existing insurers, but if so they would have to be so tightly regulated that they would lose all competitive distinction and simply be acting as de facto agents for a regulated public program. The insurers would, of course, fight tooth and nail against any such plan because it totally destroys their business model, but that’s the whole idea, because their business model is the core of the problem.

One might be skeptical if this is politically possible in the current climate without major progressive political changes, but that’s a different question. The fact that it works well in other similar countries is proof enough that it’s worth doing. Canada is a particularly compelling example because it’s so socioeconomically similar to the US.

436

…“keep pretending?”

Is that the extent of your rebuttals now?

You concede you can’t get to UHC through political means only when you admit that 2-3% of people will not be covered after your tweaks are finished. I’m not pretending you haven’t answered my question. You simply haven’t answered my question.

437

You think private insurance for someone 80 years old would be cheaper than Medicare?

438

I didn’t say that, did I?

But, just for the sake of argument, I suppose it could be, if it worked like a renewable life insurance policy that you started when you were young.

But I don’t care about insurance or who is insured. That’s really not the issue, is it? The actual issue is access to quality healthcare at a reasonable price. That’s what I care about.

People talk about Sweden and other countries with single payer, but these are not without their issues and drawbacks as well. I read a report yesterday (sorry, not on the internet, but can’t cite) that the average wait in Sweden for someone to see an oncologist after they’ve been diagnosed with prostate cancer is now 270 days. Sweden is dealing with a crisis of scarcity. This is more or less happening everywhere. They fail with access to.

Another issue with single pay is that those countries that implement it are being subsidized in a very real way by our health care system. Almost all of the innovation, the new drugs, the new techniques come out of our system. There is little incentive to innovate and advance medicine under single pay.

But our system is now the worst of both worlds, regulated and beuracratized into an unwieldy monster, with both a single pay and an insured option, the latter of which is only available reasonably as an employment benefit. We disincentivized primary care, so access to that is becoming an issue.

Our system sucks, and there is not a quick fix and single pay is not the answer.

I don’t know the full answer, but I do have some broad brush strokes as to what an optimal answer looks like.

A hip replacement now can result in a hospital bill in excess of 100k. That’s another part of the problem. Even common issues can become exhorbitant. A complex major issue becomes Apollo moonshot expenditure (I exaggerate for emphasis)

It’s not tenable.

A first question then, is healthcare a right or a commodity? If it’s a right, than we should all have free access to multimillion dollar procedures that might extend our lives slightly when we face grave, likely fatal illness. Thanks to the advancement of medecine this is becoming an increasingly common issue. People want that for their loved ones.

It’s not realistic that this can be provided by society.

What then, does good healthcare look like?

Well, my dog gets good healthcare. He has quick, almost immediate access to a provider who knows him and cares about him. He has this access at a reasonable cost, with no bureaucratic fiddling, and he gets Avery high standard of care.

A decade ago, I had a dog with cancer, and a father with cancer. The dog had a much better standard of care in so many ways. The dog lived. My father did not. The system killed him, not the treatments.

Similarly, LASIK is generally uncovered. It used to be horrendously expensive, but it’s a commodity not a right, so it has become cheap.

No matter what we would like to think healthcare should be, the immutable fact is that it is a commodity, not a right. It has all the properties of a commodity and virtually none of rights. If the goal is to provide the greatest quality of healthcare to the greatest number of people at a reasonable price, we have to stop engaging in the fallacy that healthcare is a right, and start treating it like what it is, a commodity.

Food and electricity are not treated like rights. They are treated like commodities that everyone has reasonable access to at reasonable prices. We need to treat healthcare like that.

439

It’s the response you’ve earned and that you deserve. So, I’ll treat you the way you deserve to be treated.

We’ve gone in circles in this thread, with you pretending to be bothered by “ad hominem” attacks, and then accusing me of being selfish and being a liar. You ask questions, which I answer multiple times, and then pretend I haven’t answered. You talk about me “waving my hands”, when you’re the one who’s doing that.

Pretender.

I’ll remember this as we engage on future threads. I’ve figured out your act.

440

Good thing, then, that nobody suggested something as absurd as worship of The Constitution. What do you think of the idea that we actually follow the fucking thing and, if we don’t like that, we use the processes in place to make changes to it?