Expanding Medicare System for All Would Eliminate Health Care Rationing

During the debate leading up to passage of the Affordable Care Act, members of Congress thundered against the prospect of health care rationing.

Well, for reasons largely unrelated to Obamacare, we have health care rationing. Indeed, it's one of the defining features of our private insurer-controlled health care system.

The people who shed crocodile tears about health care rationing five years ago don't talk about the rationing that we have now (and had then), but they were right to be outraged. We should all be outraged that, in the richest country on the planet, people are denied needed care on the basis of wealth and income.

We should be outraged because it doesn't have to be so. Today marks the 50th anniversary of Medicare, a system that has made health coverage universal for everyone over 65 and -- at least to the extent it has not been eroded through partial privatization -- shows the way forward to eliminating rationing.

As President Barack Obama has said, there is one way to ensure that every American has a guaranteed right to health care: A single-payer system. That's a system in which the private insurers are replaced by a single government insurance program and everyone automatically is covered. As we celebrate today the remarkable achievements of Medicare, we must also commit to defend the system from attack, repair the damage done through partial privatization and expand it to cover all Americans.

How does the current system enforce rationing?

First, although the Affordable Care Act has expanded insurance coverage, tens of millions remain uncovered. The Affordable Care Act has reduced the number of uninsured by roughly a third and may ultimately drop it by half - but roughly 13 percent of the population now remains uncovered. The uninsured don't get the care they need, plain and simple, leading to tens of thousands of preventable deaths.

Second, there is substantial rationing even among the insured. There is the infuriating issue of insurers overriding doctor decisions to determine what care may be provided. And there is the sharply rising problem of large co-pays and deductibles deterring people from seeking care. Crucially, this is by design - the co-pays and cost-sharing schemes are designed exactly to reduce access to care, and this is a significant part of the insurers' approach to (artificially) reduce health care spending.

In total, almost one in four Americans report not visiting a doctor or clinic for a health problem due to financial concerns, according to a Commonwealth Fund study. Nineteen percent of Americans did not fill their prescriptions for financial reasons in 2014, according to the Commonwealth Fund study.

Third, the lack of a single-payer program enables all kinds of profiteering and irrational care decisions. The pharmaceutical sector is Exhibit One. Consider the case of Medicare itself. Medicare Part D, which provides drug coverage to seniors, is operated through private firms, and by statute is prohibited from functioning as a rational single payer -- that is, Medicare is prohibited from negotiating drug prices. Even within the constraints of the patent monopoly system, this leads to massive overspending. A just released study from Carleton University and Public Citizen shows that Medicare brand-name drug prices are 198 percent of the median cost in OECD (rich) countries. If Medicare merely matched the discounts negotiated by the Veterans Administration, it would save $16 billion a year.

Or consider the example of Hepatitis C drugs. A new crop of breakthrough drugs promises a cure to a widespread, chronic, life-threatening disease. More than 3 million people in the United States have the disease, perhaps closer to 5 million. The makers of these new drugs, Gilead and Merck, are marketing them for $80,000 - $90,000 per person. The direct result is that public and private payers are coming up with methods to ration access to these lifesaving drugs, making them available only to people who are quite sick and meet a long list of eligibility criteria. If we had a well-functioning single-payer system, it would insist on some more reasonable price and compensation for the drug makers (they stand to generate well over than $100 billion in revenue, even accounting for the discounts they are providing) and make sure everyone who needed the treatment received it, expeditiously.

Of course, while pharmaceuticals might be Exhibit One for the irrationality and misallocated spending in the current system, it's not the only one. We don't take prevention and public health seriously. Evidence-based care remains an aspiration. And on and on.

What today's Medicare anniversary should teach us is that we can do better. It's past time for our nation to move to an Expanded and Improved Medicare-for-All. Join the movement.

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