Healthcare for All in a Land of Special Interests

This transcript has been edited for clarity.

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

Medicare for All or...Medicaid for All? Or the status quo? Or expand the Affordable Care Act (ACA; Obamacare)? Or repeal every word of the ACA? Or get the government out of medicine (presumably including Medicare, the VA, the NIH, the FDA, the CDC, health departments)? Establish true socialized medicine? Eliminate all health insurance companies? Make the system consumer-driven, fee-for-service private medicine? Or what?

This year and next are years for a frank national discussion of all of these possibilities, maybe for the first time ever in our country.

Polling data demonstrate much more knowledge and interest than ever before in the breadth and scope of these possibilities on the parts of the public, physicians, and other healthcare professionals. The national political scene bristles with understanding and keen interest in exploring better ways to "deliver" healthcare. Cost escalation, sometimes to absurd levels, for many components of medicine have the public's and the profession's eyes.

What do "we all" wish to achieve? Health insurance–enabled access for all Americans to basic, affordable healthcare with an acceptable level of quality and a competent and reasonably happy workforce.

How many Americans are "covered" now? (These are from 2016-2017, round numbers.)

Total US population: 325 million[1]

Medicare: 53 million[2]

Medicaid (including ACA expansion) and Children's Health Insurance Program (CHIP): 72 million[3]

Employment-based insurance: 170 million[4,5]

ACA exchanges: 9 million[6]

Privately held insurance: 11 million[7,8]

Veterans Affairs, Department of Defense, Public Health Service: 18 million[9,10]

Uninsured: 28 million[4,11]

Because American healthcare is a $3.5 trillion annual industry and affects all of us, the fighting will be extreme. The outcome is very much in doubt. "Small" legislative language changes could produce gigantic changes in effects.

Just switch Medicare eligibility age from 65 to birth and—voilà—Medicare for All: a proven, nationally consistent system that has stood the test of time, garners high user satisfaction scores, produces our country's best outcomes, maintains low administrative costs, and pays expected fees in a timely manner.

Simply use the ACA to raise the income level for eligibility and—voilà—Medicaid for All (state by state, of course): a widely used program that provides a wider range of services than Medicare and is more amenable to cost control. Could happen. Not likely.

Incremental change does seem politically realistic. Think about lowering the age for Medicare eligibility from 65 to 55, a common age for loss of employment-based insurance. Think about raising the age for children to remain on their parents' policies from age 26 to 30. Most are healthy but often unemployed or in grad school, or caught in our gig economy with independent contractor status and no benefits.

Think honestly about major increases in eligibility for Medicaid—not only for the very poor anymore, but for working families for whom the employer does not offer satisfactory health insurance benefits.

These may be small steps, but in aggregate they could help reduce the uninsured number greatly and might even be achievable politically.

Cost control? Depends.

As the debates ensue, follow the money. American medicine is money-driven, and the many large special-interest groups (hospitals, physicians, insurance and pharmaceutical industries) will fight like demons in all domains: on the streets, in the courts, and at the ballot boxes with the best public relations (directed at the public) and lobbying firms (directed at all legislative bodies) to keep their maximum money flowing in.

Medical societies, from the American Medical Association on down, will generally support what their members support. I predict that the lower-paid specialties (family and general internal medicine, pediatrics, psychiatry) will support many of these proposals; higher-paid specialties (cardiology, gastroenterology, radiology, most surgical fields) may not.

It may be an old and hackneyed concept, but I personally believe that the public good—for all Americans—is the point, of which we should not lose sight.

This will be interesting to watch.

That's my opinion. I'm Dr George Lundberg and this is At Large at Medscape.

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