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From the Editor

Would Medicare for All Mean Healthcare for None?

As the U.S. political left fully embraces socialism publicly and more Americans go without care because their private insurance has a staggering annual deductible, there’s more support for socializing U.S. healthcare. There was talk about this back in the 1980s when I was in medical school, long before Bernie Sanders’ “Medicare for All” Act. To get a close-up look at a single payer system, I spent 2 months in the United Kingdom during my 4th year. I realize that my brief stint at the Western Infirmary in Glasgow, Scotland 3 decades ago does not make me an expert on this topic, but it gave me a perspective that might be worth comment as Congress debates the “Medicare for All” proposal.

I went to Scotland laboring under the mistaken impression that I spoke the language but quickly learned the phrase, “Can ye talk mair slow? Because a dinna unnerstaun.” When I was finally able to communicate, I found the patients colorful, witty, hard-working, and full of humor. In 1984, the Western Infirmary still used large, open Victorian wards that housed more than 20 patients for whom a modicum of privacy was provided by means of curtains that could encircle each bed. This configuration made “ward rounds” extremely efficient for the medical team but would have made enforcing today’s Health Information Portability and Accountability Act (HIPAA) laws impossible. 

Unlike the U.S., the work day for medical students started at the very civilized hour of 9 a.m. and the entire world stopped at 3 p.m. for tea. Despite being a year younger than most of my U.S. medical school peers, I was 3 years older than most of the registrars (roughly equivalent to a resident) because in the U.K., students matriculate into medical school immediately after high school. The 5-year university degree they receive in medicine is actually an undergraduate degree. 

In the U.S., the median debt burden for a medical school graduate is now more than $200,000 and paying off that student debt is getting harder with physician salaries plummeting. In contrast, the state-funded British medical schools are very affordable because they exist to train doctors for the National Health Service (NHS). However, when the state is paying for your education, the state decides who gets to have it. Only 8% of UK medical school applicants are admitted. After graduation, it’s even harder to become a specialist in any field. The goal of the NHS is to train primary care doctors.  

I owe a debt of gratitude to the brilliant Scottish attending physicians who taught me how to perform a physical examination. They were exceptional at clinical diagnosis because that’s often all they had to go on. I saw the presentation of many diseases at an advanced stage because although everyone can access primary care, access to specialists and diagnostic testing is difficult. There are long waits for a test like magnetic resonance imaging (MRI), even among patients with brain tumors, and even longer waits for neurosurgery since there are so few neurosurgeons. 

Although all the physicians I met were stellar, in a single-payer system, there’s also no motivation to ensure patient satisfaction, or to work harder than one’s peers. The registrars got a luxurious 6 weeks of vacation a year compared to our 2 weeks, which means someone is always “on holiday” and thus a lot more doctors are needed in the U.K. to keep the medical system running. After entering practice, the physician work week is also shorter for UK physicians than for U.S. physicians. Yet, strangely, despite these enviable working conditions, there’s a serious physician shortage of doctors in the U.K., which necessitates filling many positions with doctors trained outside of Britain. 

Because physicians don’t have to pay back large school debts, they can retire while still relatively young, and women (who comprise nearly half the physician work force) often stop practicing as soon as they begin having a family. The result is that patients may wait months to be seen, particularly by a specialist, and there’s a wait list for even life-saving operations, which are often performed in an outdated facilities. In addition to the rationing effect of having too few doctors, the NHS specifically rations care. 

At the Western, there were patients post-myocardial infarction on vasopressors with no central blood pressure monitoring. Back then at least, patients over 65 did not go to the ICU after a myocardial infarction because careful analysis had shown that an ICU stay did not increase one-year life expectancy. The National Institute for Healthcare Guidance (NICE) analyzes interventions from the perspective of “quality of life years” and has established the maximum price per year the NHS will pay for things like cancer treatment. They must do this because the NHS, just like Medicare, is in deep financial trouble. In fact, the only thing that enables socialized medicine to limp along in the U.K. is a parallel private British healthcare system. 

You might argue that the U.S. has created a medical culture that is entirely too profit driven and I would not disagree. Not many people other than Mother Teresa work for the good of humanity. However, I think socialism robs workers of their motivation to excel, which is why it hasn’t worked in any country, ever. On the other hand, an unbridled fee for service system raises the cost of medical care beyond what is necessary and still doesn’t ensure quality of care. We need to land somewhere between these extremes. 

The Medicare-for-All plan proposed by Senate Democrats has broad support and I can understand why. The Affordable Care Act (ACA) kept private insurance premiums in check via massive back-end payments to the payers. Once payers stopped getting these government subsidies, patient out-of-pocket costs skyrocketed, making adequate insurance unaffordable to all but the most affluent. Millions of hard-working people lost health insurance they liked and doctors they trusted so that others could obtain substandard insurance that often doesn’t cover basic things like cancer treatment. It is no wonder Medicare-for-All has appeal. Unfortunately, socialized healthcare isn’t working well in the U.K. (or anywhere else). The NHS is bankrupt, but so is Medicare. The Medicare trust fund in the U.S. is already expected to run out of money in about 2026, which has profound implications for expanding it. 

Here are some key issues relevant to the Medicare for All plan:

  • It will make having private insurance illegal because it prohibits competition against the government healthcare system. Section 107 reads, “It shall be unlawful for a private health insurer to sell health insurance that duplicates this Act.” Keep in mind that Medicare is now largely being administered by private insurance companies under Medicare “Advantage” plans, so it’s not clear to me how that gets unwound.
  • Employers cannot offer healthcare as a benefit. Section 107 also reads, “(It also shall be unlawful for) an employer to provide benefits for employee, former employee or the dependents of an employee or former employee that duplicate the benefits provided under this Act.” 
  • It will require a 40% cut in reimbursement to hospitals and physicians. 
  • Since hospitals cannot manage a 40% reduction in revenue without large reductions in staff and services, this means fewer hospital beds, waiting times for operations (e.g., cardiac bypass, hip replacements), and waiting times for diagnostic studies and procedures, just like in the UK. 
  • It includes an $11 trillion tax increase, which would still fund less than half its cost.
  • This massive tax increase will have to be levied against the middle class because there are not enough high-end wage earners to fund its huge price tag. 
  • It requires a 50% reduction in the rest of the Federal budget which means that there will have to be large cuts in existing programs like Social Security and certainly no new programs like “free college tuition.”
  • It will decrease the standard of living in the U.S. by about 15% due to massive tax increases, federal budget cuts, and the expansion of the national debt. That means buying smaller homes, driving smaller and older cars, higher prices for gasoline ad food, and less disposable income, which is exactly what you see when you visit the U.K.
  • It will lead to doctor shortages. A 40% cut in pay means that many physicians will be unable to repay their student loans. They will simply stop practicing and physician shortages will follow.
  • There will be rationing of care. Socialized systems must ration care since they can’t control demand by raising prices. Rationing is considered normal in the U.K. (Remember that hyperbaric oxygen therapy is generally not covered in the U.K. or Canada.)
  • It will probably worsen the problems we have with Medicare fraud and abuse. Since the Medicare program will get bigger, waste, fraud and abuse will get bigger.
  • It would add $14 trillion to the national debt over the next decade.

Making private health insurance illegal will remove the only safety valve that allows socialized healthcare to exist in the UK. The Congressional Budget Office (CBO) released a 30-page report (https://www.cbo.gov/publication/55150) that lays out key issues for lawmakers to consider when crafting legislation that would impact the healthcare system, which represents one-sixth of the U.S. gross domestic product. According to the CBO, the move to the currently proposed single-payer health care system would significantly affect the entire U.S. economy and every person in the country. 

To anyone who thinks Medicare for All is the answer, I would say, “Yer aff yer heid!” 

Caroline E. Fife is chief medical officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

From the Editor
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Caroline E. Fife, MD, FAAFP, CWS, FUHM
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