n the wake of several failed Republican efforts to repeal the Affordable Care Act, Medicare for all has roared back into the spotlight. Sen. Bernie Sanders’s signature health reform proposal was introduced last month, energizing the political left and generating excitement within the health care community. This week, four medical students who sit on the board of a national single-payer advocacy organization proclaimed their support for this plan in a First Opinion. They certainly don’t speak for all medical students.
The authors of that article told the story of a 7-year-old boy, hospitalized for an asthma attack, also known as an exacerbation. They conducted a standard approach that doctors use when evaluating disease: the differential diagnosis. They concluded that the root cause for his condition was “America’s private health insurance system” and went on to argue that Medicare for all is the solution to cure what ails American health care.
In medical school, we are taught to cast our differential diagnosis widely — to consider possibilities which reach past our impulse to give into the biases that shape our initial impressions of a case. Frequent asthma attacks lend themselves to a diverse set of socially related causes. They may be caused by psychological stress or environmental triggers, like mold, due to poor living conditions. Sporadic interactions with a health care provider could leave an individual’s asthma undertreated. And, of course, the high cost of prescription drugs, like the inhalers the boy needed, is an enormous and tragic challenge for too many Americans.
But can private insurance alone explain every differential diagnosis? The evidence indicates otherwise. A lack of legal resources, now being addressed by medical-legal partnerships, keep families hostage to landlords skirting ordinances that mandate fair housing. Recent increases in health insurance premiums due to instability in the Affordable Care Act marketplaces continue to price many families out of health insurance. Consolidation among hospitals has also led to increasing — and sometimes unreasonable — prices that force up insurer costs, which are often passed on to consumers. And in the past 10 years, the price of albuterol, a key inhaled medication for asthma, has gone up from $15 to more than $100 per inhaler. Other factors, both medical and non-medical, surely have contributed to the 430,000 hospitalizations annually due to asthma, too.
Clearly, the social pathologies of asthma exacerbation — and what it means about our health care system — are multifaceted. To suggest that private insurance is the only cause is an oversimplification, lending itself to political siren calls rather than pragmatic solutions. National health insurance, like the systems in the United Kingdom or Canada, may be a part of those pragmatic solutions. But the current Medicare-for-all proposal is a perfect example of a catchy slogan that lacks the detail and nuance needed to address this case, let alone reform our health care system.
The budgetary math is the clearest demonstration of its pitfalls. New taxes proposed to fund the system would pay for half — yes, only half — of the projected $32 trillion cost over 10 years. With significant deficits already weighing down the U.S. government, is it in the country’s best interest to commit ourselves to an expense we cannot come close to affording? Is it morally conscionable to saddle our grandchildren with a national debt they can never pay off? And in the case of the family who could not afford the inhalers, would we have enough money to pay for the medications and the social interventions that could have prevented this hospitalization?
There are surely ways to make smarter decisions about how we spend our health care dollars so we can subsidize health care for those who need it most. However, the current Medicare-for-all bills in the Senate and the House, despite generating fanfare across the left, fail to acknowledge and implement instruments like cost-effectiveness analysis which could enable smarter spending, even though such tools are used by virtually every country offering universal health care to their citizens today. The bills also dispense of any cost sharing by patients, which flies in the face of evidence that some cost sharing is necessary to prevent excessive utilization and keep a universal health care system solvent.
Putting aside the details of these bills, the great fallacy underlying the push for a government-run, single-payer system is that elimination of private insurance is the only way to expand coverage to those Americans who have been left behind. The Netherlands and Switzerland successfully demonstrate how universal health coverage can be achieved within the context of a health system largely dominated by private health insurance.
We applaud our fellow students for their engagement with the policies and politics surrounding health care. Indeed, we join with them in pursuit of our common goals of increased access to care for all Americans. We agree that recent efforts are wholly inadequate to solve the pressing problems our system faces. But as we argue here, Medicare for all is not the be-all-end-all solution to the incredibly complex health care problems facing our society.
As future leaders in the effort to reinvent our health care system, medical students have an obligation to provide more depth in the public dialogue around health care. Choosing not to embrace the nuances of health policy is to allow medicine to be weaponized by the political left and right, and ultimately to discredit the meaning of our words in this important debate.
We aspire to a level of discourse that matches the unbridled complexity of the system we aim to fix. We want to sweat the details, because these details matter immensely for the health care system and for our patients.
Suhas Gondi is a first-year medical student at Harvard Medical School. Vishal Khetpal is a second-year medical student at the Alpert Medical School of Brown University. The views they express are theirs and not necessarily those of their schools.