Healthcare Is Not Broccoli

Markets can work magic. Conservative economist Milton Friedman once famously held up a yellow pencil in a lecture hall (in a talk still available on YouTube) and marveled at how capital, materials, and people had mysteriously come together, literally from the ends of the earth, to create this seemingly simple yet essential tool of modern life.  Markets, he said, enable people to cooperate, without coercion from a central authority, to create wealth. He may or may not have been right about the absence of coercion—poverty and lack of opportunity can be dictators, too—but who can deny the power of markets to get stuff done?

And yet, turning to take a look at the mostly market-based American healthcare system, we have to wonder what has gone wrong.  If you have used the system lately, you probably know the drill:  expensive, fragmented care; capricious pricing; unreadable bills.  If you are lucky enough to have insurance, you will also have noticed big jumps in premiums, deductibles and copays. As a friend said recently, “The system works great until you need to use it.  Then, well, it just depends….”  

The care, the specific treatments, the heroic surgeries and procedures can be magnificent and sometimes deliver astounding, almost magical results. But the bottom line is: we pay way, way more than people in other industrialized countries with outcomes that are about the same or worse.  And many people—millions of Americans—are still not covered by affordable insurance. Markets have failed to deliver.

How come? Probably because healthcare is not broccoli.

Broccoli?  During the Supreme Court hearings on the constitutionality of the mandate to purchase insurance associated with the Affordable Care Act,  Justice Antonin Scalia asked if healthcare were not like broccoli, and if we would next be “mandating” that everyone buy and eat broccoli along with their mandatory insurance? 

But healthcare is not a product like broccoli, or a new car, or the latest cell phone, or a yellow pencil for that matter.  In the middle of a heart attack, we are in no mood to shop.  Diagnosed with cancer or another serious disease, the last thing we want to have to worry about is how to pay for the miracle that might save our life, or at least postpone our death.  Provider and patient do not meet on a level playing field.  The provider has the power;  the patient, the reluctant customer, has only her pain, and maybe a good insurance plan, or maybe not.

How can we move past this unsustainable, morally intolerably situation?

Republicans like Speaker of the House Paul Ryan seem mostly interested in cutting government programs like Medicaid and even Medicare. But if Medicaid goes it’s bound to cramp great-grandpa’s style over there in the nursing home, and many a family with a disabled child may also feel a terrible blow.  Some Americans don’t realize that the majority of Medicaid funds go to support the elderly in nursing homes who have exhausted their own savings or to help pay for care of the severely disabled whose families would otherwise be bankrupted by the expense.

Democrats, being Democrats, are divided on where to go from here.  Some, like Senator Bernie Sanders, want to move in a single dramatic step to providing Medicare for all Americans.  Others envision the states as laboratories for trying out a variety of approaches, arguing that once a state—in particular, a large state like California—has  demonstrated the effectiveness of a particular reform strategy, then other states, and eventually the whole nation, will more easily find the political will to move forward. Ultimately, this approach may offer the best hope of real progress given the relentless gridlock we see in Washington.

Recently, however, the Center for American Progress, a Washington think tank, has come up with a third alternative:  Medicare Extra for All Americans, a program that would allow Americans to buy into the existing Medicare program if they are not satisfied with their current coverage or lack coverage entirely. 

Advocates for this approach take note of the fact that 28% of nonelderly adults, or 41 million Americans, remain underinsured. That means that their out-of-pocket costs exceed 10% of their income each year, 10% being the point at which these expenses begin to interfere with paying other bills. In addition, 28.8 million Americans remained without any insurance at all in 2017 according to the National Center for Health Statistics, a federal government database.

The coverage offered by Medicare Extra would be broader than that offered by many plans currently and includes things like dental coverage and comprehensive mental health services. Premiums would be capped according to the patient’s ability to pay and complemented as needed with tax revenues from a variety of sources. Funding for existing programs like Medicaid and the Children’s Health Insurance Program (CHIP) and their services would gradually be integrated into Medicare Extra. Overall costs would go down as the plan uses its purchasing power to negotiate lower drug prices and moves away from fee for service payment to models that encourage providers to focus on keeping patients healthy rather than providing potentially unnecessary treatments and procedures.

But what’s really novel about Medicare Extra is the way it builds on choice. Those who like their current insurance coverage could keep it. No kidding. But no matter their starting point—employer-based coverage, individual insurance purchase on the ACA exchange, Medicare, or no insurance at all—Americans could also choose to switch to Medicare Extra if and when its merits become clear.

In the first year after passage of the Medicare Extra law, only those in counties without a viable insurance options could buy into the new plan, but in succeeding years this option would be expanded and eventually those in existing programs like Medicaid would be integrated into the program.

Allowing for considerable choice, especially in its first years, Medicare Extra uses market principles and a carefully constructed public option to move us toward a better and more sustainable healthcare future.  Would it actually work?  I’m not sure. Would those who oppose a direct Bernie Sanders- style transition to improved Medicare for All oppose this more gradual plan just as vehemently? Probably.

But what’s critically important is to keep this conversation going.  If we can one day finally agree that our goal is to provide affordable access to comprehensive healthcare to all Americans—as we have already done for some sectors of our society like the elderly and the military—we  will get there. We’re not as dumb as we sometimes look. We can get this done!

Will Lane, a Lecturer in English at Gettysburg College, is a lifelong resident of Adams County and currently serves as Chair of Gettysburg Area Democracy for America.