What Bernie Sanders Didn’t Say in His ‘Medicare for All’ Vision

Editor's note: This opinion piece originally appeared on Philly.com's "Health Cents". The views expressed in the piece are Dr. Rubin's own.



Senator Bernie Sanders (I-Vt.) released last week his “Medicare for All” vision: a single payer health care system that would insure coverage for all Americans. His quest comes at a time when budget-motivated Republicans are revisiting efforts to curb costs in Medicaid through spending caps. These two efforts seem worlds apart, especially to people across the country who are counting on Congress to fix the cost and coverage challenges they are facing with their health insurance.

Sanders has plenty of evidence to support his “Medicare for All” vision, taken from the experience of the many countries around the world who now provide a publicly funded, single payer health care system for their citizens. But, his announcement was as striking for what it did not say, as what it did say. And these omissions illustrate the fundamental disconnect we have between the left and the right on how to improve our nation’s health care system.

Sanders wrote in the New York Times that the move toward a publicly funded system of health care would protect Americans from the “healthcare-industrial complex,” which includes the “insurance companies, Wall Street, the pharmaceutical companies, and medical device companies.”

You’ll notice he didn’t call out health care systems, though. Perhaps because people like their doctors and don’t want to see them criticized. But, if you talk to a family who just received a bill for dad’s visit to the cardiologist, I’m sure you’d hear some angry comments about how expensive that 15-minute visit was. Same too for your friend who just got discharged for an overnight stay in the hospital for pneumonia, or your neighbor who just had their ACL repaired.

Simply put, the elephant in the room is the runaway cost of health care. Sure, the evil-doers that Sanders specifically mentioned all contribute to this problem through the costs of bureaucracy and fragmentation and profit-driven motives. But, at the root of this issue is the incredible rise in what patients are being charged for the care they need, particularly for hospital care.

Which brings me back to the partisan divide. The conservative response to these challenges recognizes that at some point we need to cap spending on health care.  That response is not wrong, as the escalating cost of health care is profoundly affecting our economy. Companies are finding it more difficult to afford health care benefits, which has led many of them to drop coverage or provide plans that increase costs passed along to their employees in the form of higher premiums out of their paycheck or higher deductibles when they seek care. Worse yet, as companies spend more on health care benefits, they don’t have the money to give out raises, which is a major reason why wages have remained flat in our country. And finally, as patients get these bills for which they now owe more money than they used to, they have less money to live their daily lives.

Sanders is also not wrong in stating that the true victims are the consumers who are paying more out of pocket, or forgoing health care coverage altogether, because they cannot afford it. Physicians are increasingly seeing patients who put off recommended screenings that are proven to prevent diseases such as cancer or heart disease. Those patients can then wind up in the emergency department with a disastrous diagnosis that could have been avoided.

Ultimately, what Sanders did not say was that to truly achieve a vision of single payer coverage, we have to talk about the cost of health care. In fact, the little detail many advocates conveniently ignore within the single payer mantra is that the countries who provide single payer insurance have a budget and spending controls similar to the caps U.S. Republicans have been discussing. But those countries couple their budgets with a defined set of essential benefits that their citizens must receive, ensuring spending controls don’t reduce access to fundamental health coverage.

Our failures to meaningfully reform health care in this country lie in the unwillingness of both the left and the right to recognize not only the strengths of their arguments, but their striking omissions. Spending controls alongside strong protections for meaningful coverage and essential benefits are the yin and the yang for addressing this problem.

If we were to achieve that, insurers, hospitals and other providers of health care would ultimately realize that the only way to meet their budgetary caps would be to develop and offer programs that reduce costly hospitalizations. We would see more investments in population health programs, which provide care coordinators and organize community programs to work with elderly patients or families whose children have complex medical issues to keep them out of the hospital. We would also see a greater investment in behavioral health and primary care programs to improve our overall health and well-being. 

So, while I applaud Sanders for his passionate fight to reform health care coverage in this country, we need to be honest with ourselves. The answer to this quagmire lies in both embracing what Sanders has recognized and also understanding that it comes with a cost.