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Our Path Forward: “Medicare For All” — Universal, Comprehensive, Single-Payer Health Insurance

As Wisconsin defends and improves the gains made in Medicare, Medicaid and the Patient Protection and Affordable Care Act – ACA (“Obamacare”), it should move towards a universal, comprehensive, single-payer “Medicare for All” health insurance plan as the most sustainable, efficient and fair way to finance our health care delivery system.

What’s the Problem?
While the Patient Protection Affordable Care Act (ACA) has significantly reduced the number of uninsured Americans, cut the rate of health care cost escalation and strengthened consumer protection, it is only a first step in the right direction. There are still about 30 million uninsured nationally,1 since the Exchanges opened in 2014 health care costs2 have still risen at nearly five times the rate of inflation,3 and the US still spends twice as much for health care as other developed nations.4 As time passes the cost to median-income families will become increasingly unaffordable. Republicans have failed to offer a viable alternative. After eight years of trashing the Affordable Care Act and blocking attempts to improve it, the bill they passed in the U.S. House would have increased costs even more, driven tens of millions out of coverage, and enabled insurance fraud. 

StateMaternal Deaths per 100,000National Rank
Indiana2.93
Minnesota5.06
Illinois7.813
Iowa8.215
Wisconsin10.929
Michigan21.05

Wisconsin has real problems when it comes to healthcare. More than 300,000 of our citizens are uninsured,5 and delivery of care is mediocre in critical areas. We have, for example (see Table 1), the highest maternal mortality rate of any of our neighboring states except for Michigan: 33% higher than Iowa, 40% higher than Illinois, more than twice as high as Minnesota, and four times as high as Indiana’s.6

StateHealth Spending per capita7
Neighboring State Average
$8,337
Michigan8,055
Iowa8,200
Illinois8,262
Indiana8,300
Wisconsin8,702
Minnesota8,871
National Ave.$8,045

Yet, Wisconsin spends more on health care than our neighbors (see Table 2). In 2014, the most recent year for which National Health Expenditure Data is available, Wisconsin’s total (public and private) per capita health expenditures were 10.8% higher than the national average ($8702 vs $8045) and higher than the $8337 average for our five neighboring states.8 This excess does not come from Wisconsin’s public health care insurance programs (principally Medicare and Medicaid). This state’s $9,608 per capita expenditures for its older Medicare population were 8.3% lower than the five-state average and 12.5% lower than the national average, while its $7,057 per capita expenditures for its poorer Medicaid population were only 3.5% higher than the national average.9 The culprit is our private insurance system.

How Would OWR’s Proposal Address the Problem?
The OWR “Medicare for All” proposal, illustrated by the chart below and compared with Obamacare (ACA) and the Trump-Ryan plan (AHCA), would retain the ACA’s consumer protections without the program’s drawbacks. Wisconsin’s diverse mix of providers — private, public, for-profit, non-profit – gives us sufficient scale to minimize wasteful marketing and administrative costs, and to realize savings through bulk purchase of prescription drugs and standardized reimbursement rates.  Medicare for All emphasizes prevention, wellness, outcome evaluation and performance audits while encouraging system-wide use of new technology and evidence-based practices, saving money and saving lives. 

The OWR “Medicare for All” proposal, illustrated by the chart below and compared with Obamacare (ACA) and the Trump-Ryan plan (AHCA), would retain the ACA’s consumer protections without the program’s drawbacks. Wisconsin’s diverse mix of providers — private, public, for-profit, non-profit – gives us sufficient scale to minimize wasteful marketing and administrative costs, and to realize savings through bulk purchase of prescription drugs and standardized reimbursement rates.  Medicare for All emphasizes prevention, wellness, outcome evaluation and performance audits while encouraging system-wide use of new technology and evidence-based practices, saving money and saving lives. 


OWR “MEDICARE FOR ALL”AFFORDABLE CARE ACTAMERICAN HEALTH CARE ACT
Universal CoverageYES. Everyone is automatic-ally covered at birthNo. About 30 million are still uninsured and by 2022 about 28 million will remain uninsured with tens of millions underinsured.No. Far worse than the ACA, 14 million additional would lose their insurance in the first year and over 50 million by 2026 the same number as before the passage of the ACA.
Full Range of BenefitsYes. Coverage for all medic-ally necessary care: inpat-ient, out-patient, prescript-tion drugs, dental, vision, substance use /mental disorders, long term care. No. Insurers can game the system, stripping down coverage, increasing premiums, co-pays and deductibles and “cherry-picking” groups for coverage.No. Insurers would leave even more services uncovered in “catastrophic” plans while increasing premiums, co-pays and deductibles.
SavingsYes. Nationally it redirects $600 billion in administrative waste, untreated co-morbidity, and inappropriate levels of care resulting in a net reduction in overall costs. No. Increases in health spending predicted to increase by more than $1 trillion over the next 10  years as administrative costs increase as a result of the state-based exchanges.No. The CBO estimate of a $150 billion federal deficit reduction over nine years by slashing Medicaid and taxes on the wealthy. It excludes the cost of increased emergency services due to reduced or eliminated medically necessary care. 
Cost Control and SustainabilityYes. Large scale costs controls such as negotiated fee schedules with providers, bulk purchasing of drugs, hospital budgeting, and capital planning, to ensure long term sustainability. No. It rescued an insurance industry that was on the brink of failure while preserving a fragmented delivery system incapable of controlling costs and drug industry profiteering. No. It will add to the problems of the ACA  by eliminating the consumer protections. The result will be decreased care and increased out of pocket expense to middle class families.
Choice of providerYes. Patients will be allowed to freely choose their doctors, hospitals and other health providers.No. Insurance companies will continue to restrict free choice of providers while limiting care.No. Insurance will impose even greater restrictions on free choice of providers while limiting care. and benefits
Progressive FinancingYes. Premiums and out of pocket costs are replaced by a progressive. fee structure based on income and wealth. Ninety-five percent of American households will pay less than they do now. No. Continues unfair health care financing whereby costs are disproportionately borne by middle and lower -income Americans and families facing acute or chronic illness.No. Further aggravates unfair financing of health care by imposing new, inequitable tax credits which exacerbate the disproportionate cost burden on middle and lower income families facing serious illness. 

Who Else is Doing This?
A better question is, “Who isn’t?” Medicare for All is a “Single Payer” health care system, the principal features of which are universal coverage paid for out of public funds with little or no out-of-pocket expense to individuals. As of 2009 this type of system was in effect in 58 countries around the world and by 2016 the number grew to 119 including virtually all European and Western Hemisphere countries. Currently, all of the OECD countries have some form of this system with the United States being the lone exception. And all G-20 countries have a health system meeting this criteria except China and the United States. 

Moreover, here in the US we already have a publicly funded single-payer system for the 55 million Medicare and 75 million Medicaid beneficiaries. When including the 9.4 million US Military Service beneficiaries enrolled in TRICARE, more than 43% of the US population is covered by some form of “universal” federally funded health care plan. Add the 22 million civilians employed by Federal, State, and Local governments and half of the US population has health care that is paid in large part by some level of government. Combining these expenditures with $66 billion Veterans Administration medical expense and the $295 billion in health care tax subsidies credited largely to employers, well over 60% of the US health care tab is paid for with public funds. In fact, our public health care expenditures exceed the combined public AND private health care expense of most other countries.

Why Not Wisconsin?
At the federal level, OWR strongly endorses enactment of HR-676, Expanded and Improved Medicare for All, which by definition would cover all Wisconsin residents. In the absence of Federal legislation, OWR strongly endorses similar legislation at the state level creating a public/private partnership by expanding Badger Care to all Wisconsin residents who are either employed in Wisconsin or have lived in Wisconsin for 12 months. As with Medicare, supplemental insurance coverage could be purchased privately.

NOTES

  1.  Henry J. Kaiser Family Foundation (2017). Key Facts About the Uninsured Population https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
  2.  “National Health Expenditures Summary, CY 1960-2016”, Centers for Medicare and Medicaid Services. Amadeo, K. “The Balance, March 2018: “The Rising Cost of Health Care by Year and its Causes” www.thebalance.com/kimberly-amadeo-3305455
  3.  “Annual Inflation Rates in America 1990-2017” Statistica”: The Statistics Portal
  4.  Sawyer, B & Cox, C. (2018)” How does health care spending in the US compare to other countries” Kaiser Family Foundation.  https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start
  5.  US Census, 2017. Quick Facts Wisconsin.  https://www.census.gov/quickfacts/WI.
  6.  Chu, A. and Posner, C. (2013) The State of Women in America – A 50 State Analysis of How Women are Fairing Across the Nation”, Table 14, pp. 37-38. Available: https://www.americanprogress.org/issues/women/reports/2013/09/25/74836/the-state-of-women-in-america/; cf.  Singh, G.K. (2010) “Maternal Mortality in the United States, 1935-2007” U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Figure 5: Maternal Mortality Rate Per 100,000 Live Births, 2003-2007, Available: http://www.mchd.hrsa.gov/; and Center for Disease Control Prevention, National Center for Health Statistics, Compressed Mortality File 1999-2006, Series 20 No. 2L, 2009. Available: http://WONDER.CDC.GOV.CMF-ICD10html)
  7. Costs include all privately and publicly funded personal health products and services. They do not include hospital contractual adjustments, bad debt, charity. They do not include; insurance program administration and research or construction expense.
  8.  National Health Expenditure Data-CMS.Gov; State (residence) Health Expenditures by state of residence: summary tables 1991-2014: Table 11: Total All payers per capita state of residence (1991-2014), Personal health Care (Millions of Dollars. Available: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html
  9.  National Health Expenditure Data-CMS.Gov; State (residence) Health Expenditure s by state of residence: summary tables 1991-2014: Table 23: Medicare per enrollee state estimates by state of residence – personal health care (dollars) and Table 26: Medicaid per enrollee State estimates by state of residence (1991-2014) Personal health care (dollars). Available: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsStateHealthAccountsResidence.html
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