1. Opinion

A better alternative to "Medicare for All" is a U.S. National Health Service | Column

Sen. Bernie Sanders, I-Vt., a candidate for president, advocates Medicare for All. There's a better alternative. Associated Press (2019)
Published Jun. 20

Health-care reform will play a major role in the 2020 presidential election. Sen. Bernie Sanders proposes a government single payer, "Medicare for All," and several other candidates support this. However, creation of a U.S. National Health Service is a far better way to achieve the goals of health-care reform — health care as a human right, cost reduction and quality improvement — while retaining the current insurance-based system that many know and love.

The current U.S. health-care system has three problems: It does not provide universal coverage, it costs too much, and it delivers less than optimal care.

As to costs, we spend 17 percent of GDP annually on health care, almost double that of any other nation; and drugs cost much more here than anywhere else. The main reason that U.S. health care costs so much is that the system is based on reimbursement of doctors, hospitals, pharmaceutical companies and other providers by insurance companies and the government — Medicare and Medicaid. That's capitalism: Competition, the theory goes, produces lower costs and better quality. However, competition doesn't work in health care because the consumer-patient with insurance has virtually no concern for costs when accessing services. The patient views a doctor who does three MRIs as better than one who does only two, and a new drug as better than an old one, even though it costs 10 times as much and is not proved to be superior. Hospitals compete by buying expensive high-tech equipment and then charge more to cover the costs, but the patient prioritizes high-tech, not costs, when choosing a hospital.

As to quality, Americans believe that we have the best health care in the world. We develop the new drugs and instruments that improve diagnosis and cure of diseases. But objectively U.S. health care is not the best. The Kaiser Family Foundation documents that maternal mortalities are six times higher than in the next 10 comparable countries and that neonatal mortalities are 70 percent higher, while patient satisfaction is among the lowest of any developed country.

Currently, though 70 percent of the U.S. population has health-care coverage — 56 percent with employer-based or private health insurance and 14 percent with Medicare — 30 percent (100 million) are under-insured with Medicaid or entirely uninsured, relying on free care from hospitals, which currently expend more than $40 billion annually for such care. Providing the reimbursement-based "Medicare for All" would not fix the glaring problems of our current health-care system — its high cost and poor quality. Replacing Medicaid and unfunded indigent care provided by hospitals with a U.S. National Health Service would provide, if not a cure-all, a major amelioration of those problems.

A U.S. National Health Service, like the U.S. Veterans Health Administration or the British National Health Service, would use facilities owned by the government and staffed by government employees. In contrast to "Medicare for All," such a government-funded service would not be reimbursement-based. It would simply provide free coverage from primary care to hospitalizations for the 30 percent with Medicaid or no medical insurance, thus achieving universal coverage. Cost-savings would come from bulk purchasing of drugs and supplies, and from making evidence-based decisions about what drugs and services to provide. Quality would be improved by providing universal coverage and from eliminating the profit motive from medical decisions.

A U.S. National Health Service would provide a yardstick against which to compare the costs and quality of our current reimbursement-based system — a yardstick that health insurance companies could use as leverage in negotiations with their suppliers and against which to measure our currently unacceptable health outcomes. Because medical decisions in such a service would not include the latest, most costly, unproven advances, most members of the 70 percent would prefer to retain their current health insurance with the medical bells and whistles that it provides, with few moving to the free system.

A U.S. National Health Service would obviously cost money, though less than one might expect because it would be substantially covered by money currently going to Medicaid and indigent care by hospitals; and it would provide better service. It would be politically acceptable because it would not take away health insurance or Medicare from anyone who presently enjoys those benefits. It would also not have a major impact on our current health-care industry — an important component of the U.S. economy employing more than 13 million people, an abrupt change that could produce economic disaster.

In short, a U.S. National Health Service funded by the government would provide universal coverage but, unlike "Medicare for All," it would begin to address the issues of cost and quality, would leave in place the current reimbursement-based system and would not rock the economic boat.

Walter G. Bradley is professor and chairman emeritus in the Department of Neurology at the University of Miami School of Medicine.


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