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In defense of medicare for all who want it

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Duke students are passionate about addressing healthcare disparities, and many use this passion to pursue a career in the healthcare field. Lately though, as many may have heard from Bernie Sanders’ rally last Friday, a recently popular John Oliver skit and a well-circulated study in the Lancet, the current healthcare system needs systemic change. 

Doctors are at the mercy of insurance companies’ formularies that regulate the medications that can be prescribed and the procedures that can be covered. There are no restrictions on the prices pharmaceutical companies can set on vital medications. Worst of all, increasing health insurance costs cyclically leads to a massive number of uninsured Americans—who have no access to negotiated rates for drugs and services and are saddled with some of the most preposterous medical bills and economic burdens. While hospitals find ways of supplementing patients against these ever-increasing costs, their attempts are limited. Duke Hospital’s Charity Care, for example, covers some inpatient costs, but provides far less relief on vital outpatient care.

So why are there so many Americans without coverage? The overwhelming reason is that many Americans simply cannot afford an insurance plan. General increases in healthcare costs combined with the added pressures from the individual mandate have far outpaced Obamacare subsidies and Medicaid expansion (which finally occured in North Carolina under Governor Cooper last year). Besides scrutiny on pharmaceutical companies and hospitals, there is rightfully plenty of scrutiny on the profits of health insurance companies. The top eight insurance companies in 2018 made over $7 billion in profits in 2018, illustrating a significant need for new policy to rein in insurance costs and improve care. 

One such approach would be Senator Sanders’ ‘Medicare for All’ bill. This bill would establish a single-payer, government-run health insurance program, and eliminate the “middleman” by abolishing the private and employer-provided health insurance system. Bernie’s rhetoric espousing the need for systemic change rings true to the values of fairness and equity Duke teaches us. We are taught to think boldly and move forward. However, lost among this excitement is another extremely bold plan: the public option. 

I found it interesting that there were 134 people who liked the ‘Duke Students for Bernie’ Facebook group while only 12 people liked ‘Duke Students for Pete.’ Perhaps students see the change advocated for by the Sanders and Warren campaigns as more radical, and therefore, more desirable. However, Duke students—along with many across the country—are overlooking the immense power held in more nuanced options.

Pete Buttigieg, among others, proposes ‘Medicare for All Who Want It’, focusing on a public option that preserves patient choice, but also works within the market to both lower health insurance costs as well as insure all Americans. With a public option, there will be a version of Medicare available to everyone, with premiums at no higher cost than 8.5% of their annual income. This would force private insurance companies to compete with this government plan in a way they’ve never had to compete before. If a private insurance plan issues unreasonable premium increases or harsh benefit reductions, then those patients affected can simply switch to the public option. If a private insurance company can’t keep up, then they will fall out of the market naturally. Likewise, no one will be discriminated against by the private insurance companies and be pushed onto the public plan due to the pre-existing conditions requirement from Obamacare. 

Also universally opposed by insurance companies, a public option would both cover everyone and bring down healthcare costs—but notably, through a free market mechanism. But why is it important to choose the public option method instead of transitioning directly to Medicare for All? The answer is because of a need for choice and humility.

There is no guarantee that a one-size-fits-all plan works for everyone. Many of the European countries with an overall socialized healthcare system still maintain a private insurance market. Even if single-payer were found to work best for over 90% of Americans, that still doesn’t mean we should abolish all private insurance. For example, certain individuals may want a plan with higher premiums but more generous benefits, while others may prefer a plan that does not need to cover top-notch pharmaceuticals. Duke students may want to keep their $2500 per semester student health insurance that prioritizes rapid access to vaccinations, physicals and campus mental health counseling, while the elderly may prioritize a larger focus on coverage for long term care and chronic disease medication.

Furthermore, while most health insurance plans are modeled after pay-per-service, there are increasingly many plans using capitation (paying a set amount to a doctor for a population), bundled payments (paying a set amount for all costs and potential complications from a procedure), reference pricing (setting a payment level and allowing patients to shop for cheaper options), patient incentives (if you’ve seen a dentist every year, your cavity fillings will be cheaper). Many of these insurance structures may lead to potentially lower cost and better care, which could not be explored under a single-payer model. We should have humility that the government plan we design may not be the best for everyone, and if it needs adjustments, won’t we be glad we didn’t kick people off their original plans?

Obama originally wanted the public option to compete with private insurance, but it was shut down in congressional negotiations. Furthermore, in a poll last year from the Kaiser Family Foundation, there was overwhelming bipartisan support for Medicare expansion in the form of a public option, supported by 74% of those surveyed. On the other hand, only 37% supported a Medicare for All plan that would completely eliminate private insurance plans. 

A public option would address both of the most crucial challenges in health policy today: guaranteeing that everyone is insured and working within the market to compel private insurance companies to cut costs and improve care, all while not forcing anyone against their will to give up their current health insurance. All of the other fantastic ideas for healthcare reform, such as eliminating surprise out-of-network bills or allowing Medicare to negotiate with pharmaceutical companies, can also be integrated into the public option. I respect the intentions of those supporting Medicare for All, but I challenge them  not just to think about Medicare for All in comparison to the status quo, but also in comparison to an alternative such as the public option. Healthcare is a human right, however, the fight should be for universal healthcare, not necessarily universal government healthcare.

James Tian is a graduate of Trinity ’15 and the Duke School of Medicine ’19 and is a passionate supporter of Pete Buttigieg and his plan for Medicare for All Who Want It.


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