Vikas Saini speaks out on Medicare For All

In a guest blog post, Lown Institute President Vikas Saini, MD, gives his thoughts about Senator Sanders’ Medicare For All bill: 

Senator Bernie Sanders unveiled his much anticipated Medicare for All bill earlier this year, bringing single-payer health care into a policy discussion that was otherwise dominated by “repeal and replace” fervor.

The bill is a universal, comprehensive insurance coverage plan for everyone living in the United States. What an incredible game-changer if it were enacted! It focuses energy in the right direction—a direction which we all need to encourage.

Universal insurance coverage is necessary, but not sufficient, to get to a real health care system.

But it will be a huge struggle to get Medicare For All passed. And even if it were passed, it would only be a start. Universal insurance coverage is necessary, but not by itself sufficient, to get to a truly equitable, affordable, and effective health care system.

The good news

Firstly, Senator Sanders deserves high praise for his tireless efforts to bring health care to the front and center of the national debate, and to force us to face the morality of letting people die because they don’t have health care coverage. He has almost single-handedly changed the entire framework of the discussion. That’s real leadership.

Sanders has almost single-handedly changed the entire framework of the health care discussion.

The centerpiece of the bill is that four years after its passage every man, woman and child who lives in the United States would be entitled to health care benefits through a simple, clear insurance plan. For the first time in history, the US would have universal health insurance coverage.

The fully implemented plan will have no cost-sharing; i.e., no deductibles, coinsurance, copayments, or similar charges, except to encourage the use of generic prescription drugs and biologics. Prescription drugs would be priced by negotiated agreement. Other out-of-pocket costs will be capped at $2,400. These provisions would obviously have a dramatic and immediate impact on affordability of health care for millions of people.

What’s missing?

Insurance coverage is only one part of our poorly functioning health care system, which is infected with the plague of profiteering amidst fragmentation, overuse, and underuse. We know that you can have coverage and still not have good access or good care. We know that there is so much waste in the system that people can barely fathom it.

A single-payer solution will not solve all those problems, and if implemented, there will be a lot more that will need to be done. We will have to tackle the redesign of the delivery system itself if we are going to have an affordable and effective health care system. Without that, we will almost certainly spend a lot more on health care than we do today.

Delivering the Right Care

The most glaring problem in Sanders’ bill is that it preserves the current fee-for-service reimbursement system, which pays providers for each service they perform. Because the bill preserves a fee-for-service, volume-based method of payments, negotiating drug prices won’t address the many other drivers of higher prices. And setting a national budget won’t change the relative flow of funds to different stakeholders, although the bill mandates a plan to ensure that “the accurate valuation of services is reviewed and published” suggesting an intent to try to use transparency to reform payments to doctors.

The bill does include potential for changes in health care delivery and planning, assigning HHS to be involved in planning for capital expenditures and service delivery; planning for health professional education funding; and encouraging states to develop regional planning mechanisms through regional offices. All of this could be very exciting and new, or could end up being minimally different from current practices, depending on the political forces that shape implementation of the bill if it is passed. Our job therefore is to build the grassroots support for more delivery system reform, not less.

More investment in primary care

Our country is facing a shortage of primary care doctors, especially in rural areas, and millions of patients lack access to basic health care services. I would have liked to see a massive investment to reorient the system toward primary care in the bill – for example by offering direct payments to PCPs on a capitated basis at twice their current compensation rate – increasing them to roughly 10% of the premium dollar  – because the ensuing savings would more than pay for it. If that were coupled with a major program for building primary health stations in every neighborhood across the country, the net savings would be staggering and the entire program would pay for itself.

The bill includes the establishment of an Office of Primary Care, responsible for developing, coordinating, and promoting policies that expand the number of primary care practitioners. Such an office would be a significant step forward towards the goal of getting primary care services accessible to all—primarily by establishing a bully pulpit for a national conversation about primary care. Its placement within the Agency for Healthcare Research & Quality, however, risks putting it outside the flow of money and power.

My overall take

Medicare For All is a major, very positive initiative that would make a huge, direct difference in people’s lives and would transfer the fiscal burden of dealing with runaway health care costs from individuals, who are in a poor position to bear them, to the federal government.

During the debate and after passage of a Sanders bill, the issues of pricing, affordability, and the impact on the national health budget will instantly become highly debated national political issues. That may not be a bad thing. At least people would be covered while the politicians bickered!

Much more troubling is the fact that there is no discussion of global budgeting of hospitals or capitation arrangements for clinical networks, so many of the features needed to create the right incentives for providing the right care are missing.

Whether the savings from insurance reform will be enough to pay for our high priced health care system is the trillion dollar question.

If Vermont is any guide, the opposition will play to people’s loss aversion regarding higher taxes, using the issue of total costs and affordability as the line of attack for opposing the bill. I’m certain that the debate will be acrimonious and full of Nobel prize levels of sophistry. What I also know is that when it comes to financing, the most efficient, least wasteful path to universal coverage is a single payer system. There are huge savings there. On those grounds alone, support for the Sanders bill should be bipartisan!

Whether the savings from insurance reform will be enough to pay for our high priced health care system without radical delivery system reforms at the same time is the trillion dollar question.

The bill and the imminent debate over it present a valuable opportunity for us to talk about the transformation that is needed to get to the affordable, effective and just system that everyone wants. It’s an opportunity for all of us to call for the creation of “a real health system” in this country.