I

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.

advertisement

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.

Leave a Reply to dudu Cancel reply

Please enter your name.
Please enter a comment.

  • Hi everyone! I’m one of the authors of the original article and would like to continue this discussion, but STAT does not publish responses to rebuttals. The four original authors wrote a response addressing the points brought up in this rebuttal, which you can read here: http://student.pnhp.org/equal-access-us/

  • The patronizing tone of this reply to an op-ed really upsets me. In an opinion piece, the goal is to be concise. I might disagree with portions of the initial piece. I may want clarification on other points. However, I wouldn’t question the intellect and depth of knowledge of the original authors. They were writing an op-ed for heaven’s sake not a journal article. Gondi and Khetpal show a complete lack of scholarly decorum that I found highly disconcerting. To top it off, they struggle to live up to their own contemptuous standard. They cherry-pick studies and ignore real world evidence. They make erroneous criticisms of the Medicare-for-all bill that are easily refuted by the bill’s text or a simple google search. Unfortunately, I have to “hold my applause” for these rude and uninformed individuals.

  • Not ranting at you as much as the woes of our health care system and the myths and propaganda surrounding the debates.

    The trigger was probably because of your comment quoted below. We in health care professions seem to have an understanding that is unique.

    “That being said, I have a lot of experience LISTENING to people in health care. I cannot think of any that I have known (one of whom I sired) that seems to have a clue how Medicare works. ”

    Yes, Medicare, ObamaCare, your private health insurance policies are ALL complicated and a challenge for anyone to understand. Just go to Medicare.gov and see how massive the website it. And there are OTHER Medicare websites just for providers like myself that define the most recent interpretation of the regulations for my profession. Many of which are designed to curb abuses, overtreatment, and documentation requirements.

    Want to have some fun? Go to HR where you work and ask to see the contract they have that describes what your employer’s policy actually covers. You will find out it is ‘classified’.

  • Dennis et al……

    You really need to LISTEN to people who spent their lives working in our health care system. I am also one and married to one. Retired, after 40+ years. We LIVED and worked through all the past ‘reforms’ in our health care system. We see with our own eyes, the failures and shortcomings of each change. I was an occupational therapist.

    After I put two kids through college, paid off the mortgage, and had enough savings and investments to retire modestly, I simply quit when I realized that my job was much like a lawyer’s.

    I made my living off of other peoples problems, Sometimes they were better off, sometimes not. My boss did not care about who got better, who was able to go home instead of a nursing home, They did not care or ask about patient outcomes. All they wanted to know at the end of EVERY day was my billable hours of therapy to Medicare and the Insurance Companies.

    My job was all about money and I did the best I could do to help the folks that rolled or limped into the therapy department.

    You should listen to people that spent our lives working in the trenches and front line of our health care system. We are experts…..

    • Dudu

      I have no idea why your rant is addressed to me. I have made no comment here other than
      — that it is a lie to say that Medicare is a single payer system when in fact by law it is a two payer system and that in practice there four, five or more payers involved
      — that it is a lie to claim that Original Medicare is run by the government when in fact it is run by five (or more if you count Part B DME) insurance companies
      — that it is a lie to claim that Medicare beneficiaries “choosing” to get a Medicare supplement is just a casual choice that just a few people make when in fact 98% of the people on Medicare are forced to choose one, two or three additional mostly private insurance policies because Medicare is so bad

      That being said, I have a lot of experience LISTENING to people in health care. I cannot think of any that I have known (one of whom I sired) that seems to have a clue how Medicare works. For example, none of them seem to know the three things mentioned immediately above in this comment. And I really resent your implication (which is not unique amount health care people) is that seniors are stupid.

  • Sigh…………… So easy to be negative. Anyone with or without any expertise in the field can come up with reasons to badmouth any idea.

    This is one more. Everyone should notice that the author offers NO SUGGESTIONS how to solve the health care system’s woes.

    We KNOW what does not work. Our failed health care system prior to ObamaCare. ObamaCare worked better but still has its flaws and problems. After all it was a product of a very large committee (Congress) guided by lobbying and campaign contributions of the providers in our heath care system to ensure they maintain the status quo for their interests and preferably improve their bottom line. For example, the stock of hospital chains went up dramatically when ObamaCare passed. More people will have hospitalization insurance. Fewer no pays. More Profit, Better dividends. Simple math.

    The rise in premiums was known from the beginning. People who opted out of paying for health care signed up the minute they got sick or injured. I personally know many who did just that. The alternative was bankruptcy or death. Who wouldn’t? That was just one flaw. There are many. Many that can be minimized or fixed entirely.

    Half the country thinks ObamaCare is a bad thing. They cite costs most often. They Badmouth ObamaCare but offer no real solutions. Most often they talk about lowering premiums but to do that, you have to reduce what you don’t get in health care coverage. You get higher deductables, Lump the chronically ill into pre existing condition categories that have super high premiums which most of them cannot afford but still call it “access” to health insurance. You get cuts to Medicare and Medicaid. Simply a shell game with the money that drives our health care system. Give financial relief to these people and screw those people. Crunch the numbers and do your focus groups to see how you can still get re elected after doing that. They have been unsuccessful doing that.
    People simply LIKE ObamaCare because what we had before did not work. Small businesses, self employed, employers not providing health coverage or adequate health coverage, etc. A big chunk of our economy and registered voters in both parties.

    Single Payer? Medicare for All? It has been tried and proven successful. Yes, some of the attempts had their problems and their fixes. But many European countries are quite satisfied with their national health care system and the cost of providing it.

    One of the problems with ObamaCare and the health system prior to ObamaCare is simply that the hospitals, professionals, and vendors charge what they can get away with, bill the insurance company who does not care because the just pass those increased cost on through the escalating premiums they charge AFTER they make sure they make billions in profit. There is no cost containment. Free enterprise and competition does not work. You get sick or hurt, you go to the ER. Your doctor tells you which hospital to go to because he works there. There is no ‘consumer choice’ in obtaining health care. You don’t shop around for a ‘inexpensive’ hospital. If there was a ‘cheap’ hospital, would you really want to go there for your second rate health care? No, Americans want the best health care money can buy. Preferably using someone else’s money.

    With Medicare for All, Medicare should, can, and will be able to simply tell the hospitals, doctors, therapists, suppliers what they will pay for their services. They will be able to regulate costs. An aspirin given to you by a nurse in the hospital will no longer be billed at $50. If everyone actually has the same insurance, you and I who can afford to pay health care premiums will no longer have to subsidize those patients care that have no insurance. That will lower cost DRAMATICALLY. Before ObamaCare, 45% of hospitals billing was not collectable. You and I had to pay for those costs in escalating premiums. That is what I mean by DRAMATICALLY.

    Since what we had before ObamaCare was a failure, it is certain that we should not return to that system. Either fix ObamaCare and require EVERYONE to have ObamaCare or equivalent through private insurance OR give a single payer system a go.

    But remember the health care industry OWNS Congress. They paid for their election. So good luck until you and I DEMAND it at the ballot box.

  • Well you’re both a bit young to be quite so reactionary…and you really should take some time to understand the federal budget and economic productivity…but I doubt you will.

    So given it’s easier to ‘know’ what you’e against rather than what you’re for…what would you proise…taking O’Care as a starting point?

    • Not sure who you are “accusing” of being young but my position on health insurance in the US has always been to divorce it from employment altogether and create a system of universal healthcare that takes profit out of the insurance to save the almost 40% of the costs that go to paper pusher, coverage deniers and stockholder profits. What is going on with dennis is about as reactionary as one can get. Sad and angry guy I think.

    • With Sue Fraser Frankewicz you have the typical navel gazing leftist. Not able to refute anything I wrote, the leftist reverts to type with an ad-hominem attack. Surprised he or she did not call me a racist. And I would guess George directed his comment at the authors of the article, given the theme and authors of the article, young medical students.

  • denisbyron,

    Ttraditional Medicare is a perfect example of a single-payer system. That there is an alternative, for profit option, does not change that fact. You are being disingenuous I fear.

    • Sorry but you are totally wrong in your statement that Medicare is single payer. By law Original Medicare is a two-payer system with very high co-pays and all kinds of per-incident and lifetime limits on how much will be paid on a beneficiaries behalf.

      Furthermore you use the adjective “traditional” in front of Medicare. That term typically refers to the use of Medicare Parts A, B and D with a private fee for service supplement and often separate dental insurance. In that case, there are six payers involved.

      The question is: do you simply not know this or are you purposely deceiving readers?

    • No denis, you are the one being deceptive. One payer, the federal government pays my medical bills for hospital care and doctors and other providers. That is where the cost saving is, no profits made on my back.
      I can choose to add coverage for dental or drugs but neither of them are “traditional medicare.” Neither is the medigap policy I choose to carry.

      So, at best, there are two payers, me and CMS, the Center for Medicare and Medicaid Services. BTW: I am both a retired medical social worker who was working with and educating seniors about their Medicare choices for decades and a recipient of Medicare paid health care.

    • Sue Fraser Frankewicz

      Tie yourself up in knots much? You wrote two short paragraphs. In the first sentence of the first paragraph, you call me “deceptive.” In the first sentence of the second paragraph, you admit I am right that Medicare by law is a two payer system. That’s deceptive

      And you left out the fact that I provided that the two payer Medicare system is so bad in terms of massive co-pays and lifetime and per-incident limits and lack of many required medical services even being covered that almost everyone on two payer Medicare has to go and get a third and often a fourth and often a fifth additional payer just to be financially protected. You write “I can choose” hoping the casual reader will not know that 98%-plus of the people on two payer Medicare feel forced to so choose.

      I am on Medicare too. So what? I hope not too many seniors took your advice.

    • Sue Fraser Frankewicz

      Probably worth adding (because now I think the problem is that you just don’t know much about Medicare) that of course “profits are made” on your back.

      Do you really not know that Original Medicare is totally run by five insurance companies, three of whom are publicly traded for profit companies (Anthem in New England), one of which is a for-profit mutual and the fifth of which is like Blue Cross Blue Shield of Massachusetts (called Wisconsin Physicians Services).

      Do you think there is a million civil servants sitting somewhere in Chevy Chase processing Original Medicare claims. Wow?

  • It is true that the cost side needs to be addressed, but let’s not make a problem that has been solved by every other industrialized country seem hopelessly complex to solve. A single payer system does drive down the costs of payment and providers if you give that single payer the ability to negotiate prices with pharma, med device companies and providers. It is a pretty advantageous bargaining position to control all, or nearly all, of the medical spending. Within reason, they can name their price and pharma, med device and providers can either accept that price or find a new line of work. It would not be in the government’s interest to make it unprofitable to be a medical company or unattractive to be a medical provider…. but they would also eliminate the windfall profits to the pharmas and specialty doctors with three homes and a Ferrari.

  • It’s nice to see that some medical students actually put thought into practical problems and solutions instead of letting bleeding hearts bleed the system dry. The original article worried me as an older physician that students don’t understand the realities of cost.

    • Never mind that these pro-Medicare-for-All students do not understand cost. They don’t even understand Medicare. United States Medicare is not single payer

Sign up for our Morning Rounds newsletter

Your daily dose of news in health and medicine.