A volunteer hands out a poster as Vermont independent Sen. Bernie Sanders was set to address a “Medicare for All” rally in downtown Columbia, S.C. on Saturday, Oct. 20, 2018 (AP/Meg Kinnard)

This is what doctor visits would look like under Medicare for All

Experts explain how your healthcare would change if we were to shift to a Sandersesque Medicare for All model


Shira Tarlo
July 14, 2019 5:00PM (UTC)

In the Democratic presidential race, "Medicare for All" is one of the most-discussed policy proposals for overhauling and revamping the nation's health care system. The phrase is cheered on the campaign trail — even by some Republicans — and promoted by a host of presidential candidates.

White House hopeful Sen. Bernie Sanders, I-Vt., moved the health care debate to the center stage of the 2020 Democratic presidential primary in April after he rolled out a new "Medicare for All" proposal. Several top Democrats vying to take on President Donald Trump in 2020 have embraced the measure since Sanders popularized it during his first presidential run in 2016, while other candidates have served up more moderate proposals that would build more gradually on the public-private model of coverage that is currently in place.

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Sanders's Medicare for All plan is essentially an expanded version of Medicare, the federal insurance program that now primarily serves roughly 44 million people age 65 and older and some with disabilities. It proposes reaching universal health coverage by moving the country from a fragmented network of public and private financing — in which patients receive care from multiple providers related to patient preferences, physician referrals and provider-specific factors — to a government-run plan, in which almost every individual is covered by Medicare. It would prohibit employers from offering private plans that would compete with his government-sponsored option, though it would keep the Veterans Health Administration and Indian Health Services.

The measure, which seeks to eliminates premiums, co-payments and deductibles, proposes covering virtually all health expenses, including: inpatient and outpatient hospital care, emergency services, primary and preventative care, prescription drugs, mental health and substance abuse treatment, maternity and newborn care, pediatrics and home- and community-based long-term services. Dental, hearing and vision care would also be included.

Sanders has stated that Medicare for All would allow Americans to keep their insurance plans even if they change jobs. Some experts have argued that the senator's proposed government-run program would make the country's health care system easier to navigate, as consumers would no longer have to figure out whether services or providers are "in-network" or "out-of-network" and have their choice of doctors and hospitals across the country.

Amelia Haviland, a statistician and professor of public policy at Carnegie Mellon University, said consumers are likely to have a "pleasantly different" experience with a shift to a Medicare for All system.

"There is no caution at the point of care at all," Haviland told Salon. "There's no restriction on what doctor you can keep. There's no restriction on what doctors you can see. There's no worrying about whether this doctor is 'in-network.'"

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She noted that Sanders's plan addresses the "patient experience," which she said focuses on questions such as:  "Can I pay for this? How do I need to arrange my care so that I can pay for this? Which provider can I see? When can I see them?"

From the patient's perspective, coverage under Medicare for All "may not look that much different than it does now. It may just be that there's somebody different paying the bill at the end of the day than before," Allison Hoffman, a health law and policy professor at the University of Pennsylvania Law School, told Salon. "There's nothing in Sanders's plan that directs a change in the way that health care is delivered."

Lindsay Wiley, a health law professor at American University and the president of the American Society of Law, Medicine and Ethics, explained: "Under traditional Medicare, there's not the same concern about restrictive networks. There could be situations where a doctor is not accepting new patients but you wouldn't have to find a list of the doctors who have entered into a contract with your particular private insurance plan."

Hoffman also pointed out that Medicare for All would produce a system with lower administrative costs, as doctors and nurses would no longer have to spend time transferring medical records between providers, sorting out insurance bills, filling out forms and negotiating with insurance providers.

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"The process from a physician's perspective would be way simpler," she said. "They wouldn't have to have an entire office filled with people who are billing for all of that care. It would greatly reduce administrative costs and complexity — and the same is true for individuals as they're trying to choose their health plan or even use their health plan."

Hoffman said Sanders's proposal would be "much more straightforward than the kinds of health insurance we have now."

The projected cost of Sanders's plan remains unclear — the Congressional Budget Office (CBO) hasn't scored it — but it would likely cost tens of trillions of dollars. Sanders has said he would finance it through a host of taxes and by letting the government set health care prices.

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Health insurance in the U.S. remains one of the most expensive in the world and coverage remains increasingly out of reach for millions of Americans. Sanders has stressed that his Medicare for All plan has "nothing to do with health care. It's all about greed and profiteering. It is about whether we maintain a dysfunctional system which allows the top five health insurance companies to make over $20 billion in profits last year."

Sanders has proposed extending Medicare rates across the health care system in order to lower health care costs — an idea known as centralized price setting. Most countries with universal coverage set prices, too, by relying on a single government entity to negotiate prices with hospitals and manufacturers. The U.S. does it, too — Medicare, Medicaid, and the Veterans Health Administration all negotiate much lower prices than private insurance companies for the same services — but it doesn't have a central body to negotiate prices for all consumers and every private plan is negotiated individually. Medicare, for instance, tends to pay health care providers significantly less than private insurers for the same services.

This tenet of Sanders's bill has raised questions from consumers, experts, doctors, economists and hospitals about the government's role in centralizing prices. Some Americans have made their suspicion of increased centralized authority clear, while others have expressed concern that setting prices could massively cut hospital revenue.

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Haviland explained how extending Medicare rates across the board would impact providers: "For a provider who mostly sees Medicaid patients, [Medicare for All] would lead to a big raise. For a provider who mostly sees Medicare patients, that would be the same thing but with much less hassle than what they had before. For providers who mostly sees patients with private insurance, that's a big pay cut."

"Payment rates for private insurance are about 40% higher than Medicare, and Medicare rates are about 20% higher than Medicaid, so if rates all go to Medicare levels then there are serious questions about what would happen to provider supply," she added.

Some critics of Sanders's plan have gone so far as to argue that extending Medicare's payment rates across the health care system would cause a massive doctor shortage and force hospitals to shutter, especially those in rural communities that are already struggling financially. They argued that some providers could try to offset any cuts to their reimbursement rates by laying off millions of workers and limiting the care they provide.

There was concern that the U.S. could suffer from a worsening doctor shortage before the passage of former President Barack Obama's signature legislation, the Affordable Care Act, or "Obamacare," in 2010 and before the plan's expansion of Medicaid in 2014 and 2016. Research shows a doctor shortage under Obamacare, which insured roughly 20 million Americans, didn't happen.

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Democratic presidential candidate John Delaney, a former congressman from Maryland, predicted that Medicare for All would force all hospitals to close.

"If you go to every hospital in this country and you ask them one question, which is, 'How would it have been for you last year if every one of your bills were paid at the Medicare rate?' Every single hospital administrator said they would close," Delaney declared at the first debate of the 2020 primary race. "And the Medicare for All bill requires payments to stay at current Medicare rates. So, to some extent, we're basically supporting a bill that will have every hospital close."

There is currently not enough evidence to support Delaney's claim, and experts Salon spoke with indicated that the possible effects of Medicare for All on hospitals would likely be varied. They said that while some hospitals might take a big financial hit under a single-payer system, others might make more money.

Some experts, in fact, have argued that hospitals should make less money. They stated that U.S. health care spending is significantly higher than that of other developed countries and that the country's sky-high price tags for health care services need to be addressed. Research suggests that hospitals, especially those with great market power, are among the key drivers of rising health care costs for private insurance because they're able to negotiate much higher costs for care. Increased prices of health services and high administrative costs related to the enormous complexity of the country's health system also contribute to America's enormous health care spending.

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In addition to questions about reimbursement rates, Sanders's plan has come under intense scrutiny from Republicans and conservative policy experts who have expressed concern that the large influx of patients into the health care system could lead to longer waiting times and decrease the quality of care. Others have argued that pharmaceutical price controls would stifle innovation.

Experts Salon spoke with said criticisms that patients would face long wait times to get a doctor's appointment could have some truth to them, but noted that there is little evidence that Medicare for All would decrease the quality of care.

"If you provide coverage for 30 million people who weren't getting access to health care and they start using health care then obviously there's going to be more demand," Hoffman said.

Meanwhile, Haviland argued that Medicare for All could actually improve the quality care because "the provider will not be spending a bunch of time trying to figure out billing for 15 or 100 different payers and they will not be negotiating prices with 100 different payers, the provider will, presumably, be able to spend more of their time on providing care."

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For now, many aspects of Sanders's bill remain unknown, including its total cost, design and political feasibility.

"Bernie's proposal right now is extremely generous. It's really an aspirational bill — and that's not a bad place for starting a discussion," Hoffman said.


Shira Tarlo

Contact Shira Tarlo at shira.tarlo@salon.com. Follow @shiratarlo.

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