Don’t get me wrong: The funding is important. But the most important overarching question is what kind of health-care system we want.
Once we’ve decided that, we can figure out the best way to pay for it. Warren’s solution might be good or bad on either point, though what we have right now is really the worst of all possible worlds: A system with horrific problems, costing more than any system in the world, and paid for in ways that are inequitable and unsustainable. Would her plan be better?
Here are the major features of Warren’s Medicare-for-all (M4A) plan:
- All Americans would get coverage through a unified system run by the federal government. No more varying employer plans, individual market plans, skinny plans, COBRA, provider networks or the rest of it. Everyone has insurance, full stop.
- Benefits would be comprehensive. Warren would include not only standard coverage that is included in most existing plans, but also things such as dental care, vision care and long-term care, that usually aren’t.
- How you pay would change, and you’d probably pay less. Right now if like most people you get your insurance through your job, your employer pays premiums, you pay a portion of those premiums, plus you pay deductibles and co-pays. You’d pay none of that under Warren’s plan; instead, your employer would essentially shift its portion of the cost, paying the government a tax based on how many full-time employees they have instead of paying an insurance company.
- There are no new taxes on anyone but the wealthy. This was a key question that Warren has now answered: Taxes on most people would not go up, though she would institute a wealth surtax on billionaires and create a financial transactions tax on Wall Street. In addition, Warren would recapture what states now spend on Medicaid to fund this system.
- Prescription drug costs would be cut. Warren says that with aggressive negotiation with drug companies, she can bring down costs by 70 percent for name-brand drugs and 30 percent for generic.
- Bureaucracy would get streamlined. Right now we spend hundreds of billions of dollars on maintaining an intricate system of negotiation and billing between insurers and providers. A single-payer system doesn’t eliminate those costs completely, but it would bring them down significantly.
- Providers would feel some pain, but not as much as they might expect. The reason American health care costs so much is that we pay more for everything, from drugs to medical devices to MRIs to a doctor’s visit. In an M4A system, the government can bring down those prices, but if you do it too quickly or drastically, you could threaten providers and generate a backlash from doctors. Warren says providers will be paid at 110 percent of current Medicare rates, “with appropriate adjustments for rural hospitals, teaching hospitals, and other care providers.”
Warren’s plan makes a lot of assumptions, particularly about the multiple streams she plans to use to raise money. And some people will react by saying, “Oh no, there are trade-offs in her plan? Intolerable!”
But there are trade-offs we live with now — some pretty awful ones. Orthopedic surgeons can make $750,000 a year, which is good for Porsche dealerships, but it also means higher premiums for everybody. Hundreds of thousands of people have jobs in the health insurance industry, and insurance companies make billions of dollars in profits; the trade-off is that all of us have to pay for that with our premiums. We have tens of millions of people with no coverage at all. Our current trade-offs are a disaster.
And of course, you could point out that something like this will never pass through even a Democratic-controlled Senate. But that’s the wrong place to start. The place to start is to ask: Would we be better off if this plan were in place?
If the answer is yes — which I think it unequivocally is — then we can begin working toward something that gets us as much as possible of what’s good about this plan (or others).
We’ve suffered under our current system for so long that many have trouble imagining that it could be any other way. But it can be another way. In every other industrialized country, they look at the United States and think we’re insane. The idea that someone could go bankrupt because they had an illness is bizarre to them; “medical debt” is something that exists in no other wealthy country on Earth. The idea that someone wouldn’t go to the doctor when they have a problem because they’re worried about their deductible is abominable. The idea that millions have no coverage is a moral outrage.
So imagine if you literally never had to worry about health insurance again. If you need a checkup or get sick, you go to the doctor. You don’t get a bill, much less a “surprise” bill for thousands of dollars. You don’t have to worry about staying in a job you hate because the insurance is good. Money is just no longer a part of your worries about health.
That’s the future we should try to bring about. You might think Warren’s plan is a good way to get us there. Or you might think a more incremental plan has a better chance of passing, putting us on the road to that future. Or you might favor something else entirely.
But whatever plan you find most compelling, we should never forget that what we have now is a practical, financial and moral catastrophe. If we decide to change it, we can.