Opinion: Medicare For All Vs. Improving The ACA

Commentary

The latest Democratic presidential debate did sort out more about the candidates' positions, and it highlighted some deep disagreements on healthcare.

All of the Democratic candidates support universal coverage, and that healthcare is a right of all Americans. How they propose "Medicare for All" differs. Some support improvement of Obamacare such as reducing deductibles and other out-of-pocket costs, and having every state offer Medicaid to lower income Americans (Joe Biden's position). Most of the candidates who support keeping Obamacare (and private insurance) with expanded Medicaid also want to add a public option to buy into Medicare.

Most of the "progressive" candidates' are proposing a single-payer system and therefore ban all private insurance, while turning overall responsibility to cover Americans to the federal government. The argument was heated at times, and some comments were interesting-- such as the claim that candidates who opposed the Medicare for All single-payer proposal (that bans all private insurance) were promoting "Republican talking points."

The argument of Sen. Elizabeth Warren was that any Democratic candidate who warned against taking away 160 million Americans' option to continue with their current private insurance would be playing into the Republicans' hands. Her opinion was if the candidates didn't agree with her single-payer solution they are helping the Republicans' position on healthcare, and she chided them for talking "about what we really can't do and shouldn't fight for."

The position of President Trump and most Republicans who want to completely eliminate Obamacare is however in stark contrast to the moderate Democrats' position who support universal coverage by improving Obamacare. Obamacare, if allowed to expand Medicaid and offer all the subsidies in the original law, would cover virtually all Americans. The only Americans not covered would be those who could afford it but choose not to buy healthcare insurance.

In response to the concern brought up about the higher cost of the single-payer proposal, Sen. Bernie Sanders stated that hospitals under his plan would have less administrative cost and would save money by eliminating all the paperwork generated by private insurers.

Administrative work (such as staff or physician phone, fax, computer and other paperwork) -- to satisfy innumerable rules and regulations for healthcare providers -- is a huge task and very costly. A recent study reported that the average physician spends $99,000 per year on all the administrative burdens, and physicians employ on average over 4 staff members to assist with the many administrative burdens.

Sanders is right, that burdens caused by private insurers would be eliminated, but every hospital and physician can recite innumerable Medicare requirements that take their staff and physicians many hours a day to satisfy. The fact is, bureaucracy that generates rules and regulations will not go away, it could even be worse with a government-only healthcare system.

The Congressional Budget Office analyzed the possibility of a single-payer system and warned it would be very disruptive to switch over to the new system. The disruption to healthcare and patients would be far greater than Obamacare was.

Sanders' claim that his single-payer plan would be less expensive is in conflict with the independent, non-partisan Rand Corporation whose estimates are that although there are some administrative savings by doing away with all the private insurers, there would be much greater cost increases in a number of areas.

The single-payer proposal would need significant tax increases to cover the increased total cost of their proposal. No single-payer proponent has been able to explain how to avoid the $30 trillion cost of this single-payer proposal. Getting consensus on who, how, and the amount for everyone to pay in higher taxes seems impossible.

The comment by John Delaney that he had spoken with many hospital administrators who told him that Medicare for All single-payer proposals would cause them to close their hospitals apparently passed without reaction by Sens. Sanders and Warren.

Medicare payments, without private insurers' higher payments, are not enough for most physician services and hospitals to stay open, and private insurers often pay as much as 25-50 percent higher for the same services. Medicare has particularly been shortchanging rural physicians, and the critical shortage of rural physicians would only worsen without the private insurers' higher payments.

Medicare has not been a reliable or consistent partner in paying physicians. Most physicians recall the Medicare Sustainable Growth Rate's numerous payment cuts and delays in the last 15 years. For example, in one year there were five delays in payment, and almost every year physicians had to beg their legislators to spare them from 5 percent SGR Medicare cuts.

Iowa physicians are also victims of Medicare payment adjustments (large cuts) called geographic practice cost indexes (GPCI) that have never been based on accurate data, and the source of many years of controversy that has never been addressed. Many Iowa physicians, not just rural physicians, could not stay in business and would likely head to other states where Medicare pays much more for physician services.

Most Iowa physicians have been willing to accept lower payments for Medicare and Medicaid patients, but if private insurers went away, losses on many services could cause many physicians to close their practices in Iowa.

Democrats who push the single-payer solution are gambling that most voters will choose their plan-- but if they can't convince the moderate and independent voters that the high cost and major disruption is worth it-- their high stakes gamble could result in loss of Obamacare's coverage of 20-30 million previously uninsured and insurance reforms that have for the past ten years protected 100 million Americans from losing coverage for their pre-existing conditions.

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