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Winning Medicare for All? "I Like Our Chances"

Despite insights, Time magazine's cover story falls short on remedy

In his recent Time magazine article, Steven Brill paints a vivid and rather depressing picture of the perverse malfunctioning of our health care system – overpriced and technology-addicted – and he acknowledges some of the advantages of Medicare.

Sadly, however, he shies away from an endorsement of the obvious solution: an improved Medicare for all, i.e. single-payer national health insurance.

I’ll come back to that a little later. However, let me first say that Brill masterfully illuminates much of what’s wrong with U.S. health care.

Take, for example, the “chargemaster” list: an archival, bizarrely hyper-inflated price list in each hospital based on some long-lost secret formulas and automatically inflated over time.

As a physician and health policy researcher, I’ve long known about the massive charges offered to non-contract payers (read: individuals not covered by a public or private insurer), charges that are completely meaningless for costing studies because they’re almost never paid in full and don’t represent the real resources used to provide care. However, what Brill lays out brilliantly (pun intended) is the following:

  • Some very poor (lower-middle income) people actually do pay the sky-high chargemaster rates.
  • There is a cottage industry (growing, I’m sure, if nothing else due to this article) to help those hapless souls negotiate steep discounts on these ridiculous bills.
  • Hospital administrators either refuse to discuss the chargemaster list or offer up the most heinous, transparently nonsensical justifications for using it.
  • Perhaps worst of all, the CEOs of large not-for-profit providers are paid literally millions of dollars (OK, not tens of millions like big for-profit companies, but still …), thereby introducing into a supposedly public-good-oriented setting the compensation (and marketing) tone of for-profit industry.
  • When these not-for-profits list their “charity” care they value it at the price levels in the chargemaster, even though the cost to produce those services is less than 10 percent of the chargemaster price.

In these and other instances, Brill performs an outstanding public service. However, he regrettably stops short (or his editors stopped him short) of explaining why a single-payer health care system is the only effective remedy for the mess we find ourselves in today. This despite the fact that much of what he says would lead you directly to that conclusion.

He goes so far as to quote others, including John Gunn, Sloan-Kettering’s chief operating officer, who says, “If you could figure out a way to pay doctors better and separately fund research … adequately, I could see where a single-payer approach would be the most logical solution. … It would certainly be a lot more efficient than hospitals like ours having hundreds of people sitting around filling out dozens of different kinds of bills for dozens of insurance companies.”

Yet Brill characterizes single payer, the most logical solution, as “unrealistic” and fraught with the danger of government overreach and intrusion, summarily dismissing it. Need we mention insurance-company overreach and intrusion in the doctor-patient relationship? Need we note the freedom of Medicare beneficiaries to choose their own doctor and hospital, something that would also characterize a single-payer system?

Incidentally, Brill sharply undervalues the government role in paying for health care. He says that the federal government pays $800 billion per year out of our $2.8 trillion health bill, with the remainder mainly picked up by private insurers and individuals.

The $800 billion federal spending on Medicare and the federal portion of Medicaid is right. However, when you add in other federal programs, the state portion of Medicaid, other state and local programs, health insurance for government employees, and tax subsidies, the total government contribution is over 60 percent of total health spending, and rising. Our government already spends enough to pay for universal single payer!

Single-payer health reform is clearly the answer. We need to create the meme and the momentum and the aura of inevitability to do the right thing — despite the opposition of individuals and organizations with massive vested financial interests in the private health industry. They can be overcome.

Think Lincoln and the 13th amendment. As he said (or at least Daniel Day-Lewis said in the movie), regarding prospects of passing the amendment out of Congress, despite doom-saying by his advisers — “I like our chances” (slight smile).

I like our chances on single payer because it’s now so obvious how irremediably broken our system is, and the house of cards will eventually fall. It’s all about perseverance and timing.

James Kahn

James G. Kahn, M.D., M.P.H., is a professor at the Philip R. Lee Institute for Health Policy Studies, Global Health Services, and the Department of Epidemiology and Biostatistics, all at the University of California, San Francisco. He is also past president of the California chapter of Physicians for a National Health Program.

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