Jodi L. Liu, PhD
Jodi L. Liu, PhD, associate policy researcher specializing in health-care financing and payment at Rand Corporation, a nonprofit research and policy organization in Santa Monica, California.
Bottom Line: There’s no such thing as free health care. But would a single-payer health care system cost Americans more…or less?
Single-payer health care—something that’s also referred to as “Medicare for All”—has become a hot-button issue across the country. The idea: Instead of the medley of employers, insurers, individuals, charities and federal, state and local agencies that currently pay Americans’ multitrillion-dollar health-care costs, the federal government would open up a national health plan to everyone in the country and pay for essentially all health care.
Health insurance companies would be almost entirely out of the picture. So would employer-sponsored insurance—everyone would have health coverage, employed or not.
Debate about this issue is heating up, and a lot of these discussions include inaccurate information. You might hear single-payer referred to as “free” health care (it would be paid for through higher taxes) or “socialism” (in socialized medicine, the government owns nearly all health-care facilities and employs their workers—that is not what is under discussion for the US).
The government already pays most medical bills for millions of Americans through Medicare, Medicaid and veterans’ health programs, but having it be the single payer for everyone would be a massive change in the American health-care system, which currently makes up nearly 18% of our economy, and would affect everyone in ways that go beyond health care itself. With this such a critical issue in the upcoming midterm elections (and no doubt in the 2020 presidential race), Bottom Line felt it important to provide readers with a better understanding of some of the key financial implications, including…
We reviewed recent analyses by experts who study health-care policy, and we interviewed three experts who have looked carefully at the financial implications of a Medicare-for-All type of plan. Like many Americans across a variety of philosophical viewpoints, these experts disagree among themselves about the wisdom of moving in this direction. But interestingly, they are in closer agreement about the likely costs of such a system.
The most detailed single-payer plan that has been put forth so far is the one that Senator Bernie Sanders (Independent-Vermont) introduced in the Senate in 2017. That’s the one being used as a basis for the national debate on single-payer health care.
In a nutshell, it would create one new, national health-care plan that would theoretically replace all of today’s ways of paying for health care. Everyone would be covered, though private plans still could be offered for those who wanted and could afford coverage beyond what the national plan includes. There would be no more separate Medicare just for seniors, no more separate Medicaid and no more Obamacare.
In addition to the traditional medical expenses covered by current Medicare, the proposed plan would cover vision, dental and hearing expenses. There would be no out-of-pocket costs for services—meaning no premiums, deductibles or co-payments. The concept of “preexisting conditions” would not exist because everyone would be covered no matter when an illness began. Taxes would rise to fund the program…but beyond those taxes, Americans generally would no longer have medical expenses. In that sense, this proposal is not like Medicare because Medicare charges premiums, deductibles and co-pays and doesn’t cover vision, dental or hearing. Even so, this proposal often is referred to as Medicare for All, and you’ll hear it called “M4A” for short in the coming months and years.
How expensive would M4A be? A recent working paper published by the Mercatus Center at George Mason University, a think tank that generally advocates market-based approaches to policy, and a separate, previously published analysis by the Urban Institute, a think tank that tends to be less critical of government involvement, came to similar conclusions on that question—we’ll explore them below after a look at the costs of our current system.
One widely respected source of information about the current cost of all health care in the US is the Centers for Medicare and Medicaid Services (CMS), an agency within the US Department of Health and Human Services. Its estimate of the total amount that was spent by everyone for all health care in the US last year (2017) is nearly $3.5 trillion, with that amount projected to rise each year under our current health-care system until it reaches $5.7 trillion for 2026, the last year for which CMS has produced a projection. Total 10-year cost of the current system: $45 trillion.
The current system is funded primarily from American households (28%), the federal government through taxes (28%), private businesses (20%, mostly consisting of employer-paid health-care premiums) and state and local governments through taxes (17%).
The working paper on Medicare for All by the Mercatus Center got a lot of press when it was released in July 2018. Mercatus concluded that if the assumptions in the proposal are correct, $32.6 trillion in medical expenses would be shifted to the federal government over the next 10 years, but in so doing, they would be taking the place of payments that employers and individuals currently make to insurance companies and to providers.
Federal taxes would go up, but direct health-care costs for individuals and companies, including insurance premiums (and taxes that fund state and local Medicaid), would—assuming the plan were successful as proposed—go away.
This $32.6 trillion shift closely tracked the conclusion of the less heralded 2016 study of M4A by the Urban Institute that was released shortly before Sanders formally introduced his bill. It said that health-care outlays shifted to the federal government would be $32 trillion over the 10 years from 2017 through 2026.
Much of the press coverage of the Mercatus paper mischaracterized the $32.6 trillion as the “cost” of M4A, as if it would add that amount of cost to the US health-care system…when in fact it was not added cost but just a change in who sends money to health-care providers. The Mercatus paper actually found that if the system described in the M4A proposal were successfully implemented, total health-care costs in the country would go down.
However, it is important to understand that focusing on this $32.6 trillion also was potentially misleading in another way—it might be understating the cost of M4A.
That’s because that figure was derived by using certain assumptions about cost savings that are built into the Sanders M4A proposal.
These savings include such things as eliminating $1.6 trillion of administrative costs over 10 years by no longer paying insurance companies to be middlemen in our health-care system…about $846 billion in lower, federally negotiated drug prices…and tremendous savings—$5.3 trillion—from paying for all health care at Medicare payment rates, which are lower than rates currently paid by private insurance companies and higher than Medicaid payments.
The concern, as the Mercatus paper notes, is that such savings assumptions are assumptions. The assumed much lower fees paid to health-care providers would be far less certain than other cost savings and lead to other questions about provider availability and job satisfaction on the part of providers.
To address the uncertainty, the Mercatus paper included two different 10-year scenarios—one in which the M4A proposal’s reduction in provider payment rates was factored in…and one in which it wasn’t (in other words, in which the government is unable to reduce provider payment rates).
Note that in both these scenarios, there also is one area where an M4A cost increase is factored in—increased use of health care from the roughly 30 million Americans who under the current system either can’t afford or choose not to have health insurance…from some people who do have insurance but who would use no-deductible M4A more heavily…and from the inclusion of dental, vision and hearing coverage.
What’s the financial bottom line? Here are the numbers for the five years from 2022 through 2026 based on the Mercatus M4A scenarios and on CMS projections…
It’s important to note that the numbers above are estimates, and no one knows what the exact usage of these services would be. Health-care cost estimates have been wrong before.
In addition, there are financial considerations beyond just America’s total cost of health care…and other considerations beyond just financial ones. Although most current Medicare beneficiaries are satisfied with that system, the quality and availability of care under a much expanded government-managed system are areas of concern. Would there be enough providers? Would patients be able to get in to see providers in a timely manner? If the system didn’t deliver on its promises, would Americans need to purchase additional coverage from private insurers, much as many do now when they buy supplemental Medicare policies?
Another concern is the apportionment of the total cost—Americans would no longer need to pay directly for health insurance or for medical care, but to enable the government to pay our medical costs, taxes would be raised—so whose taxes would rise the most and whose the least? And many employees of health insurance companies (currently totaling about 470,000 people) would have to find new jobs.
Conversely, the current health-care system has serious faults that are proven—including relentlessly skyrocketing costs (far higher per person than in any other country)…continued lack of coverage for tens of millions even under Obamacare and ongoing fear of losing coverage for others…and the need for employers and providers to devote vast resources to managing health coverage for their employees and patients, respectively.
Under single-payer health care, instead of being able to reduce today’s private payment rates to current Medicare rates, as is noted in the Mercatus paper, the more likely scenario would be “payment rates being set higher than they are under current Medicare law and lower than those now paid by private insurance.” In other words, a system in which health care costs the country more than what the Sanders M4A proposal suggests…but less than what the country will be paying for health care if no change is made to the system…and with everyone covered.
Grand irony: Considering the two M4A scenarios above—one with significant payment cuts for providers and one with no payment cuts for providers—the midpoint of those two possibilities comes out to a total health-care cost of $5.18 trillion per year, almost exactly the projected cost to the country if our current health-care system is retained—one difference being, of course, universal coverage. So it may be that the cost of health care in America is not the biggest issue in this important debate.
Questions for everyone to consider include these…
How much value do you place on having everyone covered?
And who do you trust more to manage the health care you receive—the government or insurance companies?
