The mainstream media and their moderators of the Democratic debates have been focused on creating conflict and controversy among the Democratic candidates over their health care proposals. They, and some of the candidates, continually pit Medicare for All against alternative vehicles to provide health insurance to more Americans. They focus on Medicare for All’s costs and who will pay them as opposed to its benefits and savings. They typically ignore the issues of quality and efficiency.
Moreover, the mainstream media, their debate moderators, and some of the candidates miss the big point:
Democrats are talking about health care policies that would:
- Expand coverage to more Americans,
- Ensure coverage of a broad set of services, and
- Reduce out-of-pocket costs for consumers such as co-pays and deductibles.
Meanwhile, Republicans in Congress and the White House are trying to:
- Reduce the number of Americans who have health insurance by limiting access under the Affordable Care Act (aka Obama Care) and limiting the number of low-income people covered by Medicaid,
- Limit the range of services that are covered,
- Increase the number of people in insurance plans with high out-of-pocket costs, such as co-pays and deductibles,
- Cut $845 billion from Medicare over the next ten years, and
- Expand the privatization of Medicare by increasing the number of people in private Medicare Advantage plans, even though these plans cost the government more than traditional Medicare, have more restrictions on access to doctors and hospitals, and make it harder to access care, particularly expensive care, when one gets sick. 
Despite these major differences between the parties, the media and the debates have been deep in the weeds of policy details, focused on the cost of Medicare for All and how to pay for it. Because Medicare for All is a major restructuring of our health insurance system, there will be major differences between how health care is paid for today and how it would be paid for under Medicare for All. And there would be significant transition issues.
The alternatives to Medicare for All that some of the Democratic candidates support would also be expensive government programs, but no one seems to discuss that. If these alternatives were to cover anywhere near the number of people Medicare for All would cover, their costs would be similar to those for Medicare for All, if not higher, due to the inevitable inefficiencies in a system of multiple, competing, for-profit health insurers. Senator Warren has put forth the most detailed proposal on health care of any of the candidates. I will summarize it in my next post.
Medicare for All will generate significant cost savings. The overall and per patient costs in the U.S. are very high by international standards – almost 18% of our overall economy and more than $10,000 per person per year compared to 7% to 8% of the overall economy in other countries. Even a study by a right-wing think tank estimated that Medicare for All would save $2 trillion over ten years. The Congressional Budget Office recently estimated that a proposal in Congress to have Medicare negotiate prices for just 25 drugs would save $345 billion over ten years. This estimate implies that the savings from the bargaining power of Medicare for All on all health care spending would save far more than $2 trillion over ten years. 
Medicare for All would also improve health outcomes, an issue that has been largely ignored by the media and in the debates. From an international perspective, not only are our health care costs very high, but our outcomes are poor.
Also largely ignored by the media and in the debates are the costs of NOT having universal, affordable health insurance:
- 5 million people without health insurance for all of 2018 and another 63 million who are under-insured (i.e., have plans with high out-of-pocket costs that are likely to cause financial hardship if a covered individual gets seriously ill or injured).
- Medical costs lead 530,000 people to file for bankruptcy each year. Between 2013 and 2016, the most frequent reason families filed for bankruptcy was health care costs, even though over 90% of Americans had health insurance.
- 57 million people had trouble paying their medical bills in 2018.
- Tens of thousands of people die unnecessarily each year due to lack of access to health care.
- 44% of people didn’t go to the doctor when they were sick or injured due to cost.
- 37 million adults didn’t fill a prescription in 2018 because of cost.
- 36 million people skipped a recommended treatment, test, or follow-up because of cost.
- 34% of cancer patients had to borrow money from family or friends to pay for care.
Roughly a third of the $3.6 trillion spent annually on health care in the U.S. (i.e., $1.2 trillion) goes for expenses other than actual, direct health care services. These include costs such as administrative paper shuffling, advertising, profits, executive compensation, and nice office space for insurance companies, as well as more than $500 million a year spent on 2,500 lobbyists. In Canada, these administrative overhead costs are about a third of what they are here. The U.S. system with multiple payers, multiple forms, multiple sets of rules, and complicated billing spends 12% of overall costs on billing-related administrative expenses, while Medicare spends only 2% on these costs. 
A study recently published in the Journal of the American Medical Association (JAMA) finds that 20% – 25% of our current health care system spending, about $760 billion per year, is waste, which it analyzes in detail. The largest category of waste is the $266 billion per year in administrative costs. Changing to a single-payer system, such as Medicare for All, would largely eliminate the great and wasteful complexity of the multiple payment and reporting requirements of the various private payers.  
The second largest category of waste, over $230 billion per year, is prices that are higher than they would be with more competitive markets or the price controls that are common in other countries, particularly on drug prices. A single-payer, Medicare for All-type system maximizes the ability to negotiate prices with providers for services, drugs, and medical equipment.
If identified strategies for reducing waste were implemented, the savings of $200 – $300 billion per year would pay for health insurance for the 27.5 million people (8.5% of the population) who lacked health insurance for all of 2018  – even if our current high costs remain unchanged.
In my next post, I will summarize Senator Elizabeth Warren’s proposal for Medicare for All, including how the federal government would pay for it and the savings for middle and low-income households, for employers, and in the health care system as a whole.
 Johnson, J., 10/3/19, “Warnings of ‘stealth privatization’ effort as Trump signs Executive Order expanding Medicare Advantage plans,” Common Dreams (https://www.commondreams.org/news/2019/10/03/warnings-stealth-privatization-effort-trump-signs-executive-order-expanding-medicare)
 Dayen, D., 10/22/19, “The Medicare for All cost debate is extremely dishonest,” The American Prospect (https://prospect.org/politics/medicare-for-all-cost-debate-is-extremely-dishonest/)
 Hightower, J., July 2019, “Here’s the straight skinny on Medicare for All,” The Hightower Lowdown (https://hightowerlowdown.org/article/heres-the-straight-skinny-on-medicare-for-all/)
 Shrank, W.H., Rogstad, T.L., & Parekh, N., 10/7/19, “Waste in the US health care system,” Journal of the American Medical Association, (https://jamanetwork.com/journals/jama/article-abstract/2752664)
 Frakt, A., 10/7/19, “The huge waste in the U.S. health system,” The New York Times
 Census Bureau, Nov. 2019, “Health Insurance Coverage in the United States: 2018,” https://www.census.gov/content/dam/Census/library/publications/2019/demo/p60-267.pdf)