Medicare- for-All

For every complex problem there is an answer that is clear, simple, and wrong.

Henry Mencken (1880-1956)

With 99 days to go before the midterms, when the fate of ObamaCare may be decided, people are debating how best to cover the uninsured.

I’ve been talking to three Democratic internist friends, contemporaries of mine, about ObamaCare prospects and they all say the answer is simple: Medicare-for-all.

Medicare-for-all is a simple, direct, and compellingly attractive answer. Medicare has worked for 50 years. People like it. It reeks of compassion.

Above all, Medicare-for-all would remove, minimize, or control those profit-mongers - drug companies, device-makers, business-men of every ilk, those proponents of capitalism -from the medical-industrial- complex. Business and medicine don’t mix. Never mind that profit is the life-blood of capitalism and socialism, for that matter. Without profit, social programs are not feasible. Don't sweat the details. Regulate the hell out of those greedy business bastards. That is the answer.

In any event, Medicare-for- all assigns clear responsibility to government. No one need worry anymore about who pays for care. Big Brother does. We all do. It is health care utopia – one for all, all for one, and everything for everybody, within rationing limits of course.

There is one problem - with the aging population, life-spans soon stretching to over 90, governmental managerial bureaucratic inefficiencies and perpetual cost overruns- Medicare-for-all is unsustainable. Even in its present form, Medicare is the largest and fastest growing share of the national budget. It will be consuming 20% of it by 2050. Compare that to the 4.4% now spent on the military.

Even now, Medicare does not have the managerial skills to implement a Medicare-for-all program – it has to outsource care. Just this week, Congress reached a deal to spend $10 billion to cut waiting times for Veterans in the VA by outsourcing care to the private sector. Think of The VA as a single payer microcosm of Medicare-for-all. The appetite of government for more money as a solution never ends.

In my conversations with my three internist friends, they all said they admired the late Arnold Relman, MD, who died last week at age 91.

Now there was a visionary of Medicare-for-all. As editor of thee New England Journal of Medicine Relman advocated single-payer by putting doctors on salary in large integrated groups and removing the profit motive from medicine.

Separating medicine from business is not so easy. Hospitals, which are businesses, make up 30% of health spending, and are the largest businesses and biggest employers in most cities. Health care hires 10% of Americans. Physician services comprises 10% of tax revenues for most states. Businesses offer health coverages for 156 million Americans. Business-minded entrepreneurs and innovators develop the medical devices and drugs that advance medicine. Health plans are mostly for-profit businesses that must satisfy investors.

So much for the health care-business quandary. Relman was an articulate powerhouse in presenting his point of view. In a moving tribute to Relman in the July 24 New England Journal of Medicine, the Journal’s president editors had this to say.

“Between 1977, when he assumed the role of editor of the Journal, and 1991, when he retired from that position, Bud wrote more than 100 editorials on a wide range of topics. His writing style was lucid and direct, and he framed his arguments with great clarity of thought. “

“He was a master in the use of the bully pulpit, and he wrote passionately about many aspects of health care, especially voicing his unshakable opposition to the intrusion of business interests into the practice of medicine. He fought against commercialism and the rise of for-profit hospital systems. His views on health care, particularly his support for a single-payer health insurance system, were often controversial, and at times he became a lightning rod. He gave testimony on health care on Capitol Hill and spoke in many other venues, always with confident determination. Though his opinions often came under attack, he successfully prodded the health care community in an ongoing national debate about our health care system, the likes of which had never occurred before.”

Arnold Relman, RIP. Like my internist friends , I admired Relman. But in my view, he was an impractical idealist, caught up in a single-payer dream that will never die even though it has been debated, deflated, and defeated for over 100 years.