This weekend I canvassed in Grimes, Iowa, a small town ten miles west of Des Moines. In recent years, the area has become an attractive destination for young couples starting families, who prefer the calm and affordability of Grimes to the bustle of the city. Brand new housing developments line both sides of the gravel road running through the center part of the town, and many of the residents I spoke with were still unpacking boxes.
One of the more striking conversations I had was with a recently divorced mom who lived in one of these new homes. After I delivered my scripted spiel about Elizabeth Warren, she invited me in — I gladly accepted the reprieve from the blistering Iowa winter. The house was still mostly unfurnished, and we spoke for a few minutes at the front of the doorway while her twin boys wrestled on the wooden floor behind us.
She told me that Elizabeth is one of the candidates "on her radar", but she hasn't made up her mind. I probed a bit more. She told me that she recently hurt her hip, and just moving around the house has been a struggle. I asked if she tried seeing a doctor or physical therapist. She replied that she didn't have time. She paused, then added: "And it frankly would be difficult for me to afford physical therapy. The boys have their own medical appointments they need, and those are more important."
I was struck by the matter-of-fact tone used to describe such a sacrifice. In the two weeks I've been in Iowa, I've heard similar stories: I spoke with a 60-year old man in Urbandale who was postponing cataract surgery until his landscaping business picked up. I talked to a young couple in Des Moines who liquidated their 401K to cover the cost of their autistic son's speech therapy. I had a phone call with an independent contractor in his 40's who couldn't remember the last time he had gotten a physical, and didn't have the "time or money to deal with insurance".
The stories I've heard in Iowa are not uncommon. 1 in 3 Americans report skipping a medical appointment due to cost in the past 12 months (Commonwealth Fund Survey, 2016)
According to a recent report from The Commonwealth Fund, 45 percent of U.S. adults ages 19 to 64, or 87 million people, are either underinsured or have no insurance at all (of which a disproportionate share are African-American). In 2018, 57 million people had trouble covering their medical bills, and 40 million people didn't go to a doctor to check out a health problem because of costs. Meanwhile, America spends about twice as much per person on health care than the average among our peer countries while delivering worse health outcomes than many of them.
But hearing these uniquely American stories over the past couple of weeks has helped to crystallize for me what no amount of data could: Our healthcare system may be fine for some people. But for many more, it simply is not good enough. America is home to the best health care providers in the world, and yet tens of millions of people can't get care because of cost, forcing families into impossible decisions.
The Path Forward
All Democrats, and even some Republicans, acknowledge that our healthcare system is flawed.
The question, which has become a focal point of the Democratic primary contest, is what is the best policy to ensure adequate, dependable coverage for those 87 million Americans?
Bernie Sanders and Elizabeth Warren advocate transitioning to a single-payer national health insurance plan, also known as "Medicare for All". Under this system, the federal government finances healthcare, while the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services.
"Under single payer, there is just one big everybody-in and nobody-out network. All people have it. All doctors and hospitals take it. In fact, they are competing to take you as patients (the best of capitalism!). No wall street corporations (aka insurance companies) getting between you and your doctor. Everybody has the same comprehensive coverage, with no copays, deductibles, or point-of-service fees to block you from getting the care you need; it is guaranteed coverage. It is freedom and choice of having healthcare regardless of changes in job or other life circumstances. Peace of mind that it is always there." — Dr. Stephen Auerbach, M.D.
More moderate candidates, like Joe Biden, Amy Klobuchar and Pete Buttigieg, accuse Warren and Sanders of taking an ideologically hardline on the issue of healthcare, and argue that a better way forward is to provide a public option for healthcare while maintaining a private insurance market. They argue that a public option plan would preserve choice, cost less, and is more palatable for the American public. Mayor Pete is particularly adept at presenting his plan, "Medicare for All Who Want It", as a middle-ground solution that offers the best of both worlds.
The problem, according to healthcare policy experts, is that the only government programs that are sustainable are the ones that serve people at all income levels. Social Security and Medicare have stood the test of time because Americans, regardless of income, know that they and their families will participate — and so these programs are properly funded. On the other hand, programs that only serve low-income families, like food stamps, public housing and Medicaid, have historically struggled to receive adequate funding. Those at the top of the economic food chain are less enthusiastic about programs they bankroll for the benefit of others. It's the Achilles' heel of the Affordable Care Act, and would be the downfall of any public option plan.
According to Dr. Auerbach, having one network is also what makes Medicare for All work economically: "For-profit insurers will always favor a younger and healthier population — those that are less likely to get sick. This in turn will make the public pool more expensive, and doom it to fail. A single risk pool removes the adverse selection of insurance companies."
Debunking the Myths about Medicare for All
The two most common attacks against Medicare for All are that it removes freedom of choice, and that it is too expensive.
As one of the top contenders running in the moderate lane, Mayor Pete has emerged as a vocal critic of a single-payer system, despite acknowledging that he would eventually like to see us get there. The fact that he frequently misrepresents his competitors single-payer proposals while pushing a policy that creates the illusion of choice is bad enough. What's worse is that he does so behind a guise of good-faith policy disagreement, all the while securing millions in campaign funding from insurance industry executives.
Dr. Auerbach, like other proponents of a single-payer system, take particular exception to the portrayal of Medicare for All as a policy that eliminates choice: "On the contrary, it increases real choice and freedom to choose any doctor and hospital — the choice most Americans care about — not the false choice of choosing from an insurance company plan that you are eligible for and can afford, which still leaves you with a limited network, copays, and deductibles."
Contrary to the depiction of Medicare for All as socialized, government-run healthcare, the reality is that neither the government nor insurance bureaucrats will be making decisions about an individual's health care. Unlike the private insurance industry, national health insurance provides complete freedom of choice to choose whatever provider suits one's needs.
Single-payer healthcare is also affordable. Most single-payer proposals, including Senator Warren's Medicare for All plan, would generate funding from three sources: taxes on corporations and the top 1%, targeted spending cuts in the federal budget, and stricter tax fraud enforcement. These sources, coupled with the savings Medicare for All would generate by eliminating the staggering waste of the private insurance system, would reduce national health expenditures from 2020–2029, according to analysis by the Urban Institute.
This is Big, Structural Change
Much of the media opposition to Medicare For All is funded by drug companies and insurance companies — actors with entrenched financial interest in the policy debate. But it would be wrong to dismiss the concerns, and genuine fears, millions of Americans have about how disruptive Medicare for All would be to America's health care system.
What will it mean for doctors? What will it mean for employees at insurance companies? What will it mean for union members who like their insurance plan?
Every successful effort to move the United States to create and expand new social programs, including Social Security and Medicare, has required multiple steps, and has disrupted existing jobs in the short-term; it is why every credible Medicare for All proposal has a significant, multi-step transition built in.
Senator Warren's plan proposes a three-year transition period in which health care workers and union representatives are consulted at every stage of the process. Supplemental private insurance would still be available (only duplicate coverage not allowed). Employers currently offering health benefits under a collective bargaining agreement will be able to reduce their Employer Medicare Contribution if they pass along those savings to workers in the form of increased wages, pensions, or other collectively-bargained benefits. Hospitals will have reduced administrative overhead and be able to invest in new types of jobs, and doctors will be able to spend more time with patients.
Doctors in the U.S. spend only 1/4 of their time actually with patients (Physicians for a National Health Plan)
Doctors in the U.S. express greater frustration with the RX approval process (Physicians for a National Health Plan)
But make no mistake. This is big, structural change. Our health care system is broken. It needs to be disrupted. Lives are at stake.
Any patchwork attempts to provide healthcare that do not do away with private insurance as we know it will cost more, and leave more people uninsured, than universal health care.
The Conversation I Will Have with My Kids About Healthcare
In my first Sociology course, I learned about the sociological imagination — a term C. Wright Mills coined to describe the vivid awareness of the relationship between one's life experience and the wider society. I have come to appreciate how studying Sociology has made me view my own life through a historical lens.
I think back to my parent's stories of growing up in a time when segregation was the status quo. Their parents grew up in a time when women were not expected, or not allowed, to work. I often think about the social phenomena of this era that will bewilder my children.
I think healthcare will be one of them. I think I will tell my kids that when I was growing up, you had to go through for-profit insurance companies for medical care. The insurance company you had was based on your employer, and when you didn't have a job or were between jobs, you usually didn't have insurance. I will explain that the doctors or hospitals you could go to depended on which providers were in your insurance company's network. At the doctor's office, there were out-of-pocket costs, and sometimes medical fees were so high that nearly half the country chose to forego necessary care. I hope that they will look at me in disbelief, like how I looked at my parents and grandparents when they spoke about what life was like back in the day. Because I hope, for them, guaranteed healthcare will be the status quo.