I am going to make a prediction here. No matter whom we elect in
2020, Bernie or Trump or anything in between, Medicare for All is not
going to happen in America. One can run an electrifying campaign on the
promise of Medicare for All, or be indignantly against it, but this is
pure theater on both sides. I don’t know if God can make a rock so big
and heavy that even He can’t lift it, but I do know that the government
can make corporations so big and powerful that even the government
itself can’t break them.
For decades, our government encouraged the healthcare industry to
consolidate vertically, horizontally, and obliquely so it can achieve
“economies of scale” and, therefore, lower consumer prices. In the last
couple of decades, the government also compelled the industry to
computerize its operations, because technology makes everything better
and cheaper. Once the resulting monopolistic behemoths were summoned
into existence, it was time to nationalize the whole lot, into one super
monopoly, with super technology and super economies of scale. The only
other example of such government monopoly in America is the military.
Obviously, our standing armies must be, by definition, a national
monopoly, but note that the Navy is not building its own ships, and the
Air Force is not building its own planes, and the Army is not
manufacturing tanks. The government is contracting with private
suppliers for pretty much everything, from butter to bullets. The
military-industrial complex is a network of very large and utterly
corrupt contractors for the government, yielding more power over foreign
and fiscal policy than Congress, the president, and all citizens put
together, while delivering practically nothing either on budget or on
time. A powerful military is essential to America’s safety and global
success, so we grind our teeth and keep paying. And medical care for
hundreds of millions of people is at least as important.
I am not entirely sure how people think Medicare for All is going to
work. Are you folks envisioning an angry President Bernie dragging
Samuel Hazen into the Oval, wagging his finger at him, and making an
offer Mr. Hazen cannot refuse? Something like, “I will pay $50 per head
and not a penny more, because healthcare is a human right, and if you
want to be a disgusting millionaire or billionaire, go write a
bestselling book, like I did …”, at which point Mr. Hazen will be
hanging his head down in shame and gratefully take the $50 deal. Upon
his return to Nashville, Mr. Hazen will immediately schedule book
writing workshops for all HCA department chiefs to compensate for
cutting all salaries in half. Yeah … no, that’s not how this works.
Go ask Northrop Grumman or Lockheed Martin or General Dynamics or
even Boeing or Booz Allen or any other “beltway bandit” how getting
money from the Feds really works. There are well-greased revolving doors
between the Pentagon and its contractors. There are stock options and
executive positions for high-ranking federal employees. There are 535
people in Congress responsible for allocating budgets, and all 535 are
for sale.
Most of this infrastructure is already in place for healthcare too,
and building the HHS Heptagon shouldn’t take very long. The American
president has little to no power over federal spending, and even less so
when it comes to large procurement contracts, as the current occupant
of the White House discovered the hard way, during the Lockheed F-35
kerfuffle.
Clearly, large health systems will survive and thrive under a
Medicare for All law, but how about private health insurance? Future
President Bernie says they will all be banned. Is that so? Currently, a
full third of Medicare beneficiaries are insured and “managed” by a
handful of large private health insurers. Medicare is paying those
private contractors fixed amounts of money per head for their services.
Medicaid is doing the same for most of its beneficiaries, and all
military health insurance (TRICARE) is contracted out to the usual
suspects.
Basically, the vast majority of people covered by public insurance
are really insured by gigantic insurance corporations. Fact: Under the
hood, taxpayer-funded healthcare is the bread and butter of private
health insurance companies.
When future President Bernie and the hordes of uninformed supporting
characters in the 2020 elections festival say that private health
insurance will be banned, they are lying to you. What will be banned
under a Medicare for All law is your ability or your employer’s ability
to purchase health insurance directly from a private company. Instead,
the government will procure contracts in bulk as it sees fit, assign
people to them as it sees fit, and pay for these contracts with tax
revenue as it sees fit. Just like they pay for battleships, fighter
planes, bombs, tanks, and such. The U.S. military is known for lots of
great things. Value-based purchasing, and cost-effectiveness in general,
are not among those things.
Depending on whom you ask and what is included in the definition of
healthcare, Medicare for All is projected to cost between three trillion
and four trillion dollars per year, which is five times the amount we
spend on the military. This number is calculated based on costs under
current law, minus the waste generated by the cacophony of hundreds and
thousands of different insurance plans, different healthcare facilities,
and their too-many-to-count service and product vendors.
The projections do not include the effects of the inevitable massive
consolidation of everything healthcare into a dozen or so federal
contractors, able and willing to demand multi-billion dollar contracts
for services worth a few million dollars at most on the open market.
Remember the Obamacare marketplace website? Multiply that by orders of
magnitude, and you have Medicare for All.
Medicare for All is as egregious a misnomer for this plan as the
Affordable Care Act was. When they say Medicare for All, they mean
federal government procured health insurance for all. When they say
everything soup to nuts will be covered, they mean everything the
heavily indebted federal government thinks should be covered, and can
afford to cover, will be covered. When they say healthcare will be
better, more plentiful, and much more affordable, they mean please vote
for me in 2020.
Medicare for All will be built on the largely immovable foundation
our government chartered and nurtured for half a century. If you want a
glimpse into a Medicare for All future, go look at any Medicaid Managed
Care plan in any impoverished southern state, and look at the balance
sheets of the associated contractors and sub-contractors.
It doesn’t have to be this way. We don’t need to bulldoze over
everything we have, and we certainly don’t need to pretend that we can,
or that we must. And we need to remember that the proper role of
government in a free country is not to manage the health or the care of
all its citizens. Free people are not the wards of a State responsible
for keeping them healthy, productive, and happy. The role of a
democratic government is to keep predators, foreign and domestic,
including corporate ones, at bay, while providing a sturdy safety net
for the few who cannot care for themselves.
Let’s do that instead. It will be better, faster, and cheaper than the fictional construct called Medicare for All.
Margalit Gur-Arie, MSc, is founder of BizMed. She blogs at On Health Care Tech & Policy. This post originally appeared on KevinMD.
https://www.medpagetoday.com/blogs/kevinmd/82756
