Medicare for all may be next for healthcare reform

In the Journal of the American Medical Association on May 15, 1991, in our first of many theme issues dedicated to “Caring for the uninsured and underinsured,” I wrote: “An aura of inevitability is upon us. It is no longer acceptable morally, ethically, or economically for so many of our people to be medically uninsured or seriously underinsured. We can solve this problem. We have the knowledge and the resources, the skills, the time, and the moral prescience. We need only clear-cut objectives and proper organization of our resources. Have we now the national will and leadership?”

From 1991 to 2010, we did not have the will.

Finally, the U.S. “did the right thing.” The Senate-House bill that President Obama signed into law is a far cry from what I and many others wanted. But politics is, among other descriptors, “the art of the possible.”

How good or bad will this new legislation be for the country, after full implementation by around 2014? The rule of unintended consequences will have many opportunities to play out. But, let’s look at some quasi-objective scores that may help inform the answer.

In 1993, I published a set of 11 key factors to consider when evaluating a nation’s healthcare. I posited that if all were deemed equal and each was given a 9 if perfect, then an ideal healthcare system would score 99. The factors evaluate whether the health system:

1. Provides access to basic care for all
2. Produces real cost control
3. Promotes continuing quality and safety
4. Reduces administrative hassle and cost
5. Enhances disease prevention
6. Encourages primary care
7. Considers long-term care
8. Provides necessary patient autonomy
9. Safeguards physician autonomy
10. Limits professional liability
11. Possesses staying power

The total score we gave the U.S. healthcare system in 1994 was 55.

The Clinton Plan, had it been voted into law and implemented, scored a 70. The Stark mark-up of the Clinton Plan scored an all time high of 72, but that bill never made it out of committee.

In 2005, for a MedGenMed Webcast Video Editorial, I scored the U.S. healthcare system at a 52.

In an article for the launch issue of the Journal of Participatory Medicine, we introduced a twelfth category — diversity. So 12 elements times 8 for “ideal” would have rendered a top possible score of 96. The U.S. system graded at 42 in 2009.

In February 2010 at a meeting of about 300 healthcare consumers in Santa Rosa, CA, I sought their help — by a show of hands — in evaluating the 2010 (pre-reform) U.S. healthcare system across the same 12 factors. And in March in Hayward, Calif., I performed the same exact exercise with about 50 physicians. (The results are in the table.) The totals were amazingly similar at 40 and 40.5.

A quick personal scoring of the 2010 reform bill — if implemented as written by 2014 — grades at a total of 64; a substantial improvement over 2010 but far below the ideal score of 96.

Let’s grade, based upon current outcome and patient satisfaction data, an “Improved Medicare for All” proposal — which included the ability for patients to opt out or jump the queue with their own money and/or supplemental private insurance. Total 80.

Not ideal; far better than what we have or will have by 2014.

So, if it’s so much better, why did “Improved Medicare for All” not happen?

Several reasons. The President was on record (before the election) of supporting some variant of “single-payer,” as did the U.S. populace, according to much polling data. But the Congress (not the people or the administration) makes the laws and the lobbying money/power of the insurance companies, the pharmaceutical and medical device manufacturers, many medical associations, many hospitals, and many lawyers so overwhelmingly “owned” the votes of such a majority of the House and the Senate that the various versions of “single-payer” could not even garner an official forum for debate.

The intransigence of the “single-payer” advocates to stick to their noxious (connotes government monopoly) term also hurt their cause.

Government of all sorts already pays 51%; improved “Medicare for All” would jack that up to about 75%, not 100%, of a much lower total national healthcare expenditure over time, and American freedom to choose would continue. The basic goals of “Medicare for All” are to assure that all Americans have access to basic medical care and that no one (as well as the country) need go bankrupt from medical costs.

“Next time” for reform is impossible to predict; history says 40 to 50 years before new reform. I say it will all depend on the success or failure of total (not only federal) cost control over the next five to seven years.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit for more health policy news.

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