Medicare for All?

Among my Osher Institute classes has been a discussion session each week going on two semesters.  Topics vary as does level of expertise of the presenter and the presentation.  A medical professional, not physician though highly experienced in systems of medical care, selected Medicare for All as the topic.   It has made a ringing slogan for some political candidates, who I think really mean universal health coverage for all Americans, which expands the possibilities to a lot more than Medicare.  When Medicare took effect initially it replaced nothing other than some retirees having health insurance from their union or company pension.  It was also opposed by some important physicians organizations whose credibility never recovered.  Seniors and disabled people needed care that they couldn't pay for which means either they skipped what would be elective or their doctors and hospitals did not get paid for doing what could not be omitted.  It worked out well for the beneficiaries, for the practicing doctors, for the doctors in training, and for medical institutions.  The taxpayers did less well and the crystal ball gazers know the day of insolvency will come.

While Medicare beneficiaries are fairly secure except for prescription drugs which have supplanted a fair amount of surgery, and those workers or employers don't seem to mind their allotted contributions, most of the population is on the paying end.  If Medicare payments to providers do not adequately compensate the care given, then the cost gets shifted with higher payments from commercial plans and higher premiums or deductibles.  And we have a lot of Americans left out in the cold, people who may as well replace those seniors from the 1950's who could not forgo medical care but had no means of paying for it.

Most places around the world have bitten the bullet, offered universal medical benefits to their inhabitants, got some semblance of quality by accepted measures, and pay a lot less per individual than American aggregate costs, which don't cover everyone.  Medicare expansion sounds good.  An equitable system, something people are used to either for themselves or parents, and predictable if not economical cost.  Not a bad option if it didn't have to replace something, which is why some political candidates claim it as a promised initiative if elected.  However, it does have to replace something, and while uninsured or Medicaid or maybe even VA patients would do better, much larger numbers of people are already used to something else, often paid invisibly by employers supplemented by nominal payroll deductions that they never see.  Disruption never goes well, even when the status quo has a lot of room for improvement.  Siphoning off their care to create corporate infrastructure and profits does not register until the care fails, which it hasn't.

What struck me about the discussion with about a dozen Medicare age seniors of good intellect in the room was the shallowness of the understanding and the inability to articulate what they would want to accomplish.  From a patient perspective, it may be closer to VA or Medicaid for all though salaries would come from multiple employers.  Moving employees from their corporations to the Medicare rolls or people doing useful work for insurers to Medicare where the same work needs to be done but not necessarily by the same people or even the same number of people may not be worth the disruption.  And if everyplace else around the world has a process, the knowledge of those possibilities was non-existent, let alone how those places got from their starting point to where they are now.

The people in our room were 100% mullets but at least we have no influence on what happens.  The political candidates are also mullets and they can do a lot of harm.

While expertise has been gradually devalued, except maybe in the hi-tech world,this is one where people really need to defer to the experts who can examine other attempts,  determine intended upsides and downsides of multiple options, and pick one.  That's not a room of a dozen seniors and it's not a televised debate stage of ignoramuses seeking votes from other ignoramuses.