Accepted Manuscript. An Alternative to Medicare for All. James E. Dalen MD, Jennifer L Plitt MD, Neha Jaswal MD, Joseph S.

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1 Accepted Manuscript An Alternative to Medicare for All James E. Dalen MD, Jennifer L Plitt MD, Neha Jaswal MD, Joseph S. Alpert MD PII: S (19) DOI: Reference: AJM To appear in: The American Journal of Medicine Please cite this article as: James E. Dalen MD, Jennifer L Plitt MD, Neha Jaswal MD, Joseph S. Alpert MD, An Alternative to Medicare for All, The American Journal of Medicine (2019), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 TITLE PAGE / Commentary Title: An Alternative to Medicare for All Authors: James E. Dalen, MD Corresponding author U of Arizona Rancho Vistoso Blvd Apartment 45 Oro Valley, AZ jdalenmd@gmail.com Phone/Fax: Jennifer L Plitt, MD U of Arizona 1501 N Campbell Ave Tucson AZ, jplitt@aemrc.arizona.edu Neha Jaswal MD U of Arizona 1501 N Campbell Ave Tucson Neha.jaswal@bannerhealth Joseph S. Alpert MD U of Arizona 1501 N Campbell Ave Tucson, AZ jalpert@ .arizona.edu Funding: None / Conflict of Interest: None All authors have contributed to the preparation of this manuscript. Page 1

3 Two facts about US health care are beyond dispute. First, US health care is the most expensive in the world; twice as expensive as the average industrial nation. (1) Second, US health care is not the best health care system in the world. Four different studies have compared US health care to other industrialized nations. As shown in Table 1 the US has not fared well in these reports. (2-4) In the US, life expectancy is shorter, immunization rates are lower and infant and maternal mortality are much higher than in other OECD nations. (1) Our poor health outcomes reflect the fact that unlike other industrialized nations, many Americans lack access to ongoing medical care because they lack health insurance. Prior to the passage of the Affordable Care Act in 2014 there were 47 million uninsured Americans. In 2018, four years after Obama Care was enacted, 27 million are uninsured. (5) Americans without health insurance receive sub-optimal health care. They are less likely to have a usual source of health care, less likely to fill prescriptions and more likely to postpone or go without care due to cost (6). In addition, the uninsured are less like to have preventive screening tests for cancer, including mammograms, pap tests and colonoscopies. (7) Patients with chronic conditions such as heart disease, diabetes and asthma who lack a regular source of health care are at a greater risk of premature mortality than the insured.(7). Page 2

4 The impact of not having health insurance is illustrated by Table 2 which compares Canadians (all of whom have access to health care) to Americans who do or do not have health insurance (8). Note than Americans who are insured have the same access to health care as Canadians. However, Americans without insurance have less access to care. The most concerning fact about the uninsured in America is that they don t live as long as the insured as shown in Table 3. HOW CAN WE ENSURE THAT ALL AMERICANS HAVE ACCESS TO HEALTH CARE? There are two ways that this could be achieved. One, the US government could directly deliver health care as in the United Kingdom and Scandinavian countries. This is socialized medicine. In this system the government owns and operates the hospitals. Health workers are government employees. The cost of health care is paid from taxes. Health care is free to all citizens. Socialized medicine works well in England and some other countries. However, it is exceedingly unlikely that socialized medicine could ever be accepted in the US. The other way to make health care available to all citizens is national health insurance. All citizens are required to purchase health insurance; usually via employment. National health insurance began in Germany and is in place in multiple nations. Page 3

5 Canadian health care is a hybrid of these two systems. Health care is paid from taxes and is delivered without charge to the patient. However, unlike the UK, health care is delivered by the private sector. The hospitals are not owned or operated by the government, physicians are not government employees and they charge the health insurance for patient care. Many Americans don t realize that the US has had mandatory national health insurance ever since Medicare was enacted in 1965! US citizens and permanent legal residents (and their employers) must pay for Medicare by a salary deduction; beginning with their first pay check and continuing for as long as they earn income. Medicare is administered by the US federal government. (12) In 2018, the health care expenses of 57 million Americans were paid by Medicare. More than 600,000 physicians participate and nearly all US hospitals care for Medicare patients. (12) The administrative costs and all overhead costs of non-profit Medicare are much less than private insurance. (13) Medicare differs from mandatory health insurance in other countries like Germany and France in that except for those with chronic disabilities it cannot be used to pay for health care until age 65. (12) One of the major objections to Medicare for all is that it would be mandatory and would be administered by the federal government. In % of Americans said in a Pew Research poll (14) that they don t trust the US federal government. Page 4

6 Yet, polls of Americans, are strongly supportive of Medicare even though it is mandatory and administered by the Federal government. (15) POSSIBLE SOLUTIONS: MEDICARE FOR ALL If Medicare for all were enacted it would pay the medical expenses of all Americans. Private health insurance provided by employers or individuals, Medicaid, Veterans health care would cease to exist. The number of uninsured Americans would decrease to a bare minimum. Once all Americans have access to ongoing medical care we could expect that most health disparities could be corrected. Many report that installing Medicare for all, a non-profit system, would significantly reduce administrative costs, profits and overhead and would lead to a reduction in US health care costs. (13) WOULD MEDICARE FOR ALL BE PASSED BY CONGRESS? There would be fierce opposition to Medicare for All. The Republican resistance to a government role in health care is deep and persistent as evidenced by their opposition to Medicare in 1965 and the Affordable Care Act. (16) A survey in 2014 asked: Is making sure all Americans have health coverage a responsibility of the Federal government? While 70% of Democrats said yes, only 12% of Republicans said yes. (17). Health care is the largest industry in the US with 16 million health workers. (18 ) Millions of these health care workers in the health insurance business, pharmaceuticals, for profit HMOs and hospitals could lose their Page 5

7 jobs. They would certainly oppose Medicare for All! They would be a powerful adversary. There would be massive advertising opposing Medicare for all just as there was to the Affordable Care Act. They would say that this is socialized medicine (it isn t!), government style medical care with waiting lists.(19) It is very unlikely that such a massive change in our health care system would be passed by congress at the present time. ALTERNATIVES TO MEDICARE FOR ALL One possibility would be to lower the age at which Medicare begins to pay for medical care from 65 to a younger age, perhaps at age 45. This would increase the costs of Medicare and would require an increase in the Medicare payroll tax to employees and employers. The current deduction for Medicare is 1.45% to 2.35% for the employee and 1.45% for the employer. (12) Increasing the Medicare tax would face strong opposition. ANOTHER ALTERNATIVE TO MEDICARE FOR ALL The number of patients receiving Medicare could be increased by letting some Americans buy into Medicare. They would pay an increased Medicare tax until they reach 65, at which time they would pay the same as others for Medicare coverage. Since they pay their way this should not increase Medicare costs. Buying into Medicare before age 65 would be optional, not mandatory. Those pleased with their coverage by employment-based insurance or other private insurance could keep their current insurance. Those not Page 6

8 pleased with their current coverage or those without insurance could elect to buy into Medicare. If buying into Medicare were successful it could pave the way into Medicare for all. Many Americans oppose change; but our health care system must change. The US can not continue to have a health care system that is the most expensive in the world and yet leaves many Americans, those who are uninsured, without lifesaving ongoing, preventative care. We can, and must do better! References 1. Organization for Economic Co-operation and Development (OECD) 2017 Health at a Glance (2017): OECD Indicators, OECD Publishing, Paris. Health Expenditures NBC News. November 14, 2013 Boehner: Affordable Care Act can t be fixed. Available at: Accessed December 18, Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff 2001; 20: Davis K, Stremikis K, Squires D, et al. Mirror, mirror on the wall, 2014 update: how the U.S. Health care system compares Internationally. Commonwealth Fund Available at: Accessed December 22, GBD, Health care access and quality collaborators. Measuring performance on the health care access and quality index for 195 countries and territories. Lancet; 2018; 391: Keith, K. Two new federal surveys show stable uninsured rate. Health Affairs Blog September 13, Page 7

9 7. Organization for Economic Co-operation and Development (OECD) 2017 Health at a Glance (2017): OECD Indicators, OECD Publishing, Paris. Access to Care Kaiser Family Foundation. Key facts about the uninsured accessed at: Accessed December 22, Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Pub Health 2006;96: Franks P, Clancy CM, Gold MR. Health Insurance and mortality. JAMA 1993;270: Institute of Medicine, Care Without Coverage, Too little, Too Late. Washington DC: The National Academies Press, Wilper AP, Woolhandler S, Lasser KE et al. Health insurance and mortality in US adults. Am J Pub Health 2009;99: Centers for Medicare and Medicaid Services. Medicare and you Available at: medicarealliance.org/sites/default/files/217-09/cms-medicare-and-you.pdf Accessed December 20, Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the US and Canada New Engl J Med 2003; 349: Blendon RJ, Bensom JM. The public and the conflict over future Medicare funding. New Engl J Med 2013; 369: Pew Research Center. Public trust in government Available at: www:people-press.org/2017/12/14/public-trust-in-government Accessed 12/20/ Dalen JE, Waterbrook K, Alpert JS. Why Do So Many Americans Oppose the Affordable Care Act? Am J Med 2015; 128: Blendon RJ, Benson JM. Voters and the Affordable Care Act in the 2014 election. NEJM 2014; 371 Page 8

10 19. Thompson D. Health care just became the US s large employer. The Atlantic January 9, Dalen JE. Should the Affordable Care Act of 2010 be repealed? Am J Med 2011; 124: Page 9

11 Table 1 Ratings of Health Care Report Year Rating of US World Health Org /17 industrial nations Commonwealth /11 industrial nations GBD collaborators /195 nations Table 2 US vs Canada 8 Canada Insured Regular MD? 85% 85% 40% MD visit within 1 year 83% 86% 56% Can afford meds? 95% 92% 72% Table 3 US Not Insured Annual Mortality of Uninsured Americans Compared to Insured Study Year % increased mortality Franks % Institute of Med % Wilper % Page 10