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Health Policy
May 31, 2019

Single-Payer Reform—“Medicare for All”

Author Affiliations
  • 1School of Urban Public Health, City University of New York, Hunter College, New York, New York
  • 2Harvard Medical School, Boston, Massachusetts
JAMA. 2019;321(24):2399-2400. doi:10.1001/jama.2019.7031

The prospect of single-payer “Medicare-for-all” reform evokes enthusiasm and concern. Proponents maintain that a single-payer system would be the simplest route to universal coverage; every US resident would qualify for comprehensive insurance under a public, tax-financed plan that would replace private insurers, Medicaid, and Medicare. Others are concerned that costs would escalate or that the government would limit and underfund care, particularly hospital care, which commands the largest share of health spending; innovation might lag; and government may infringe on medical decisions.

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    4 Comments for this article
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    A Succinct Breath of Fresh Air Worth Reading
    James Unland, Harvard, U. of Chicago | Professor, Loyola University Chicago Health Law Institute
    This relatively short piece is power-packed, surfacing most of the key issues. Both its brevity and its breadth are impressive. That so many issues are raised is at least as important as the direction of the authors' thinking.

    I am not quite as "there" yet as the authors imply that they are. I'm still trying to grapple with the details of the "piece of toast problem" which is: how does something go from spreading a relatively finite amount of butter over piece of toast to being compelled to spread it over a city block?
    The answer might be to squeeze more butter from what the authors call "the vast health-managerial apparatus."
    CONFLICT OF INTEREST: None Reported
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    Medicare for All Increases Prospects for Medical Liability Reform
    Edward Volpintesta, md | Bethel Medical Group
    One benefit of Medicare for All is that is that it will increase the prospects for reform of the way medical liability is handled.

    The current system is over-adversarial and frivolous lawsuits are common. Many doctors see the system as abusive and exploitive, and the mere threat of a lawsuit compels them to practice defensive medicine almost routinely, raising the cost of care.

    A single-payer system with government support can eliminate the waste of money—in fact it may have to if a single payer system is to succeed in our litigious culture.
    CONFLICT OF INTEREST: None Reported
    "Medicare for All"
    Lawrence Danto, MD, FACS, Professor Retired | U.C. Davis
    Wherever mutually exclusive systems of care exist, competition increases the cost of care. Waste is unavoidably created. “Down-time” is expensive and must be accounted for. As a result, competition or choice for essential services in a controlled market drives up the cost of those services. This is a difficult consequence to come to grips with. Our U.S. health system, with funding and payment based on competing private for-profit health insurance, is sorely inefficient and vastly over expensive at best. It is unconstitutional at worst.
    CONFLICT OF INTEREST: None Reported
    Who Thinks the Government Will Pay?
    Karl Stecher, M.D. | Retired Neurosurgeon
    This is an article authored by two well known and knowledgeable people. But they are academic based, and seemingly unaware of what lurks in the outside world.

    Pay? Payment from Medicare is so pitifully low (and Medicaid is worse) that many physicians will see no Medicare patients, or limit the number they see. Reimbursement is so low that it is often even below overhead...equivalent, for comparison, to paying the gas station 60 cents a gallon.

    And Medicare as of now does not cover dental, hearing, or vision (except cataracts, glaucoma, and retinal detachment).

    When
    one hears "single payer," the average voter thinks something will be free or close to it. The physician in practice is aware of how little is paid by the government, and also aware of the wonderful world of government which has brought us the VA; the despised electronic record requirement which has a physician spending extra hours each day in documentation and largely prevents him/her from observing the patient (busy looking at a computer) versus the very important one-on-one doctor/patient observation which is more than half of communication; the burdensome expense of computer requirements foisted on physician practices; and burdensome billing forms which are longer than standard insurance forms.

    And we have just experienced Obamacare with the government claims about keeping one's doctor and/or insurance.

    No preauthorization? Today the physician has to play "Mother May I" with Medicare just as with private insurance companies, not just for permission for operations, but even for CAT scans, MRIs, and even physical therapy. And plenty of denials by the Medicare non-physician functionaries.

    And perhaps the authors are unaware of the opinion of an Ontario judge in 2006; I believe a patient had to wait two years for a hip replacement, or something of the sort. The judge opined: The Canadian system does not guarantee care. It only guarantees a place in line.

    If the authors want to focus on Medicare, let them call for an increased and somewhat fair reimbursement system.
    CONFLICT OF INTEREST: None Reported
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