July 14, 2020
I know most of the arguments against “Medicare for All.” I’ve been making them for most of my professional life as a physician:
1) We don’t need it; our current mix bag of public and private insurance coverage is adequate
2) Disrupting the private insurance industry would result in too many job losses
3) The government cannot be trusted to run a program of this size
4) We don’t have buy-in from a majority of constituents
5) We simply can’t afford it.
I’ve said all of these for 30 years. I now know that I am wrong.
Health care policy can be simplified to answering the basic question of who gets covered and at what cost. Universal coverage was once championed only by the most progressive. Then came COVID-19.
COVID has taught us that every member of our society needs adequate health care. This is not just a progressive talking point, it is the reality of infectious disease: those without proper care run the risk of acquiring and transmitting the disease to the rest of us.
The most marginalized segments of our population such as the homeless, undocumented workers, and the incarcerated still have contact with clerks in coffee shops, police officers, and staff in our emergency rooms. This was made evident when a homeless patient came to my practice’s office for wound care seven times over a two weeks period at the beginning of the pandemic before strict safety protocols were instituted. This patient subsequently tested positive for COVID-19. Fortunately, none of the staff in my practice contracted COVID from this patient. This scenario is just a microcosm of what can go wrong if we do not care for everyone.
Universal coverage is no longer charity or a luxury, it’s now medically necessary as protection for us all.
COVID has also taught us that tying insurance to employers no longer makes sense. It’s a historical accident that we even have this system: The Stabilization Act of 1942 was passed to limit war-time inflation and limited employers’ ability to raise wages, but there was an exemption for “insurance and pension benefits” which could grow “in a reasonable amount” during the freeze.
Suddenly, employers were in the health insurance business as health benefits could be considered compensation but did not count as taxable income.
When Congress rewrote the tax code in 1954, it preserved the tax subsidies for third-party insurance, and by 1964, almost 80 percent of the population had some form of employer-sponsored health insurance.
This system sort of worked until the cost of health coverage became too expensive and companies, especially small companies, reduced or eliminated coverage. Today, Kaiser Permanente estimates that only about 49 percent of Americans get their coverage this way.
COVID made it clear what a weak link this is as sudden massive unemployment can quickly result in public health catastrophe. More than 30 million people lost their jobs — and for many, their health insurance–in just a few months of lockdown. Many of these people run the risk of being suddenly uninsured.
Yes, Medicare for All will cost a lot, and it will cause huge disruptions. But disruption is part of free enterprise and innovation. Why should health care companies be exempt? It makes little sense and is almost un-American. Think electricity replacing whale oil, combustible engine replacing horse and buggy, the invention of the computer, the internet, smartphones, fax machines. Each innovation caused massive job restructuring but they also made our lives better and easier. By some estimates, Amazon has resulted in the elimination of 1.5 million retail jobs. Are health insurance jobs more vital than retail jobs? In the case of Medicare for All, displaced private insurance workers are the very ones the government would need to hire and help implement the new program.
For many years I didn’t trust the government to run a system as large as Medicare for All — not when the DMV can barely handle your license renewal. Consider our newest department, the Department of Homeland Security, which was created in 2002. DHS now has over 240,000 employees and a budget of nearly $50 billion. Bureaucracy exists within any large organization. We now readily accepted this new department after the terrorist attacks of 9/11. Aside from the extremists, no one is calling for the dismantling of major departments due to bureaucracy.
Medicare for All will certainly be expensive. Projections range from 13-47 trillion dollars over 10 years.
Critics claim that this enormous amount would bankrupt our treasury and unfairly pass down this debt to our children and grandchildren. However, other than for a short duration in the 1990s, the U.S. government has run a budget deficit every year since 1970. Our national debt is now over 25 trillion dollars and will surely grow in the future. Economists continue to debate about the meaning and consequence of this large debt.
The United States government has spent more than six trillion dollars to help support the economy during the pandemic with widespread support from both politicians and the public and very muted dissent from the traditional deficit hawks. That’s because it’s clear to politicians that the stimulus is preventing a broader crisis. Deficit spending is considered not only reasonable but a wise use of resources when it provides benefit to a large segment of our population.
The sizable cost of 1 to 4 trillion per year for universal health coverage is justifiable and may even appear to be a bargain considering the amount we have already spent on COVID, and the amount people will continue to spend on the most expensive health care system in the world. We currently are already spending nearly $4 trillion per year on U.S. healthcare. Despite this enormous amount, we still have gaps in coverage and we rank poorly as measured by healthcare access and quality index compared with other developed countries.
COVID has made clear that we need to reframe the way we think about universal health coverage. It would be naïve to think that COVID will be our last novel pathogen or last economic shock. The disruption and cost of permanent universal coverage is indeed high but the cost of not pursuing this policy will likely be much higher.
Li Tso, M.D. is a primary care physician at Mass General Hospital, assistant professor of medicine at Harvard Medical School.