With the debate over health care heating up again, Medicare for All once more is a hot topic. Sen. Bernie Sanders, I-Vt., has sponsored a new version of his Senate bill that promises to free Americans from health care concerns.
But
at the core of the Sanders bill is still the vast and fundamentally illiberal
restriction on choice for both patients and providers.
One
key provision of the bill would outlaw health care plans that duplicate
coverage. Section 107 states bluntly that “it shall be unlawful for— (1) a
private health insurer to sell health insurance coverage that duplicates the
benefits provided under this Act.”
In
other words, it will be expressly illegal for any private company or employer
to provide health benefits that compete with the government.
The
Sanders bill, however, is gracious enough to allow insurers or employers to
provide any benefit not covered in the legislation.
This
provision to outlaw private plans that duplicate government coverage, allowing only
the sale of supplemental plans, is similar to Canadian Medicare, which covers
all Canadian citizens.
In
Canada, approximately 30 percent of health care spending is private spending, with 12.4 percent
coming from private insurers. The Canadian system, however, does not include dental,
vision, and prescription drug coverage that is part of the Medicare for All
package. The Sanders bill would leave almost no room for the private sector at
all.
Where
Canadian health care leaves significant room for private health care plans, Medicare
for All would preclude a substantial amount of private coverage in America,
leaving essentially cosmetic surgery and experimental drugs excluded by the secretary
of the Department of Health and Human Services, per Section 203(b) of the bill.
Under
this regime, the government would take near complete control over the 18
percent of gross domestic product that is health spending. Private spending,
which amounts to about 45 percent of national health expenditures, would collapse.
If
Medicare for All passes, you will not keep your health care plan. And you will
not be able to find one if you so choose.
Proponents
of Medicare for All would argue the loss in choice is a worthy tradeoff, but
they will have to countenance the government’s having the final say in health care
choices between patient and provider. Title II of Medicare for All gives the HHS
secretary explicit authority to determine what items or services are “medically
necessary or appropriate for maintenance of health.”
We
already have seen the result of this in the United Kingdom’s National Health Service,
which decided to cut or limit coverage for certain procedures in an effort to
control costs. Although the NHS has deemed those procedures “unnecessary,” the
decision to perform, for instance, a tonsillectomy should be decided in the clinic
rather than by HHS.
It
is theoretically possible to avoid that kind of government intrusion into an
individual’s health choices. Enrollment as a patient in Medicare for All would not
be necessary, although it would be automatic. Likewise, participation as a
provider technically would be voluntary.
The
problem is that the bill makes it virtually impossible to practice medicine
without participating in the program.
Under
Title III, nonparticipating providers could not bill the government for
services offered under Medicare for All. And if the provider does furnish such
a service, he or she would have to submit an affidavit affirming the service
and could not participate in Medicare for All or treat anyone covered by it for
a period of one year.
Thus,
if a patient wants to avoid waiting for an appointment with a physician and contract with one
privately, that physician either would have to renounce his participation in Medicare
for All, which would cover practically everyone in the United States, or he already
must have been practicing outside the program.
There
likely would be a market for direct primary care physicians, otherwise known as
concierge medicine doctors, but it is unrealistic to expect these services to
be widely available to the average American.
In
essence, we would see a two-tiered medical system: one for most Americans, and
one for wealthy Americans. This is a common complaint in Canada, and one of the ways the
Canadian Medical Association has suggested to address it is by contracting more with,
interestingly, private providers.
Medicare
for All would make it nearly impossible to practice medicine outside of
participation in the program. Patients would have little other option than to
accept the medical decisions of the HHS secretary.
Today, about half of the $3.5 trillion a year in American health care spending is direct government spending; the rest is private health spending, mostly directed by employers.
Medicare
for All would cede that spending entirely to the government.
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