Ethics Beyond Compliance

Last year, on the 49^th anniversary of Medicare, I wrote a post advocating the expansion of Medicare to ensure that everyone in the United States can have access to basic healthcare. In the past year, I have read and heard many arguments against the expansion of Medicare and, in fact, single-payer systems in general. As I read the arguments, I realize that in a sense “Medicare for All” and “single-payer” have become a shorthand way of saying we need to guarantee “universal access to healthcare,” but I still think Medicare for All is the way to go in the United States.

I happily admit, though, that my commitment is to universal access to healthcare, not Medicare. The first step, in my opinion, is to declare that we will provide access to healthcare to all United States citizens. Take this simple idea, and make it law: We will provide healthcare to every citizen of the United States. Once that law is passed, we can have extended debates about whether Medicare can fulfill the purpose of guaranteeing that all citizens will have access to healthcare (my repetition is intentional).

Here are some of the objections I’ve heard and read to expanding Medicare along with my replies:

I don’t want to pay for healthcare for people who are too lazy to work.

Many people I talk to are extremely optimistic about their ability to pay for their healthcare in the case of extreme illness or injury. The fact that you’ve made it so far only means you’ve been lucky, not self-sufficient. Mary Brown, who sued the government over the Affordable Care Act because she didn’t want to purchase insurance, went bankrupt and was unable to pay her bills. In response to her own bankruptcy, Brown reportedly said, “”I believe that anyone has unforeseen things that happen to them that are beyond their control.”  Yes, and the Affordable Care Act was designed to reduce the impact of unforeseen illness and injury. Unlike Mary Brown, many people who become medically bankrupt had insurance but weren’t able to cover their medical bills, anyway. A study in 2007 found that three-fourths of people who were medially bankrupt had insurance.  A study by NerdWallet Health found in 2013 that “Despite having year-round insurance coverage, 10 million insured Americans ages 19-64 will face bills they are unable to pay.”

For people who do have insurance, most get it through their employers. Too many people seem to forget that when they face unforeseen illness or injury, they will also be unable to work and are likely to lose their employer-provided insurance. If not immediately, it will happen sometime further down the road. Whether the road is long or short, it leads to bankruptcy. While some are rich enough to be impervious to mounting medical debt, most of us are not. A few hundred thousand dollars may sound like a safe cushion against medical disaster, but many life-saving treatments exceed that amount quickly. Selling your house and other assets to pay your medical bills may not be a solution. In fact it probably is not a solution.

The fact is that supporting a national program to guarantee access to healthcare free from the risk of burdensome medical debt is not something you should do only for other people. It is something you should do for yourself. And it is something we should do for our country.

As a nation, we share many burdens: national defense, national safety, public health, personal security. Like infrastructure and security, we are not talking about items we can choose to forgo in leaner times. These are basic human needs. Any society that does not meet the basic needs of its citizens will falter. If we can share the cost of providing a strong military, food inspectors, fire fighters, and police, we can share the cost of providing health services. The financial life you save may be your own.

Most countries don’t have a true single-payer system.

The argument here is that many countries that do guarantee universal access to healthcare do not use a “true” single-payer system. I am willing to concede that even Medicare for All might technically require the use of more than one payer. What is important, really, is that the payers are not invested in fleecing their clients, which often seems to be the case with for-profit insurance companies. In fact, if we had a single for-profit insurance monopoly, we might find our processes somewhat more efficient but not beneficial for consumers, so it matters who the single payer is as well. Just to repeat: we must have a system that guarantees access to healthcare without the risk of bankruptcy.

Medicare is fraught with fraud and abuse.

No one can deny that fraud and abuse exist within the current Medicare system. We need greater transparency, oversight, and regulation of the system and of the providers. Also, Medicare must have the ability to negotiate prices, unlike the disastrous Medicare Part D that currently exists for prescription drugs.

Corporations will game the system.

It is true that for-profit providers, whether they are pharmaceutical companies, for-profit hospitals, biotechnology companies, medical equipment suppliers or food vendors, will strive to earn as much profit as is humanly possible. This is why we need a system that empowers taxpayers to hold bad actors accountable and demand transparency regarding pricing and profit. Corporations will serve the common good only when common people demand that they do. Fatalism is an excuse to avoid the hard work of diligence.

We need price controls.

Again, simply removing all but one payer will not, on its own, lower prices. If Medicare simply sent checks to providers for whatever charges they submitted, the United States would continue to have the costliest healthcare system in the world. Medicare must have the ability to negotiate prices and set limits on unchecked profits.

We must limit unnecessary tests and treatments.

In a pay-for-service system, hospitals, labs, equipment manufacturers, and others make money every time someone is tested or treated for anything at all. More and more studies are finding that many tests lead to unnecessary treatment, waste money, and (even worse) cause more injury and death than they prevent. Unfortunately, limiting the number of tests and treatments available to patients is likely to be perceived as (shriek) rationing.

With our current system, we trust insurance companies to refuse payments for useless or harmful tests and treatments, but we know this does not always happen. When it does, clients fear they are being denied necessary tests and treatments. They fear this largely because it is sometimes true. Whether Medicare is expanded or not, we need better ways to evaluate what tests and treatments are beneficial, and we need better ways of educating patients on what is and is not beneficial.

Movements toward paying providers for results, not services, may reduce unnecessary and harmful services greatly. It may also force patients to become more responsible for their own health.

Finally

The only real imperative here is that we, as a nation, must decide whether we will provide access to healthcare for all our citizens. Once we agree that we will, we can begin to work out the most efficient and cost-effective means for achieving our goals. Almost no one in the United States is immune from the possibility of medical disaster and bankruptcy. This is a matter of caring for our fellow citizens, but it is also a matter of caring for ourselves.

On the 50^th anniversary of Medicare, take a stand for healthcare justice.