Vermont Senator Bernie Sanders wants to reform the U.S. health care system, describing it as “broken, dysfunctional, and getting worse,” saying:
We spend almost twice as much per capita on health care as any other nation, nearly $13,000, and an unsustainable 18.3 percent of our GDP.
Yet, we remain the only major country not to guarantee health care to all—leaving 85 million uninsured or underinsured. That number has gone up recently as millions have lost the Medicaid coverage that was provided to them during the pandemic.
If Americans are uninsured and underinsured blame the Affordable Care Act (ACA). The ACA exacerbated many of the problems with our health care system. The ACA contained no cost control and tacked numerous subsidies on top of perverse incentives. This is Bernie’s bailiwick: He wants a Medicare-for-All Single-Payer health care system, claiming:
The day must come, sooner than later, when we join the rest of the industrialized world and guarantee health care for every man, woman, and child as a human right through a Medicare for All single payer system. That is the right thing to do, that is the humane thing, and that is the cost-effective thing to do.
Today, despite our huge health-care expenditures, our life expectancy is considerably lower than almost any other wealthy nation and, in many parts of the country, is getting lower. Incredibly, the gap in longevity between the rich and the poor in our country is now at least 10 years as tens of thousands of Americans die each year because they can’t access the health care they need.
The rich and poor longevity gap has more to do with lifestyle choices rather than health care. However, progressives would like to think Medicare-for-All would somehow change behavior. Income and education are highly correlated with healthy behaviors.
Sen. Sanders worries that over the next 10 years the U.S. will face a shortage of 120,000 doctors. He also believes the U.S. faces a potential a shortage of 200,000 to 450,000 nurses over the next several years. Sanders further identifies a shortage of dentists, psychiatrists, psychologists, social workers, counselors, addiction specialists, and many others. Some of what Senator Sanders says is correct but his solution is not. One has to look no further than single payer systems in Canada, and the United Kingdom to see shortages of the same specialists and health care providers. Furthermore, in those countries there are often shortages of high-tech equipment and the newest drugs. One proposal Sanders mentioned is a good idea: increasing residency programs to allow more medical school graduates to complete their medical education. Residency is required for licensure so it would make a difference. He also wants to encourage medical schools to train more primary care physicians. That too could be done through expanded residency programs but medical schools are unlikely to push students into primary care.
Single payer health care systems are designed to squeeze costs-savings out of medical care. Monopsony power is single payer systems’ secret sauce. If there is only one legal payer for health care (as in Medicare), that payer has a lot of leverage to squeeze doctors, hospitals, drug companies and medical suppliers. Price negotiations are basically take it or leave it. Squeezing cost-savings by reducing the fees earned by providers isn’t going to entice more professionals to enter the health care field. It will accomplish quite the reverse.
Sanders continues with his diatribe of words:
Every major medical organization in the country agrees that what we are investing in primary health care is woefully inadequate. They understand that focusing on disease prevention and providing Americans with a medical home will not only save lives and ease suffering. It will save billions of dollars. Providing primary care to all is not only smart health care, it is cost-effective health care.
Sanders parrots the conventional wisdom, and he is wrong. There is no evidence that boosting primary care spending will save money. Indeed, it will likely increase expenditure since many more people will see a doctor when they don’t really need to. It’s not necessarily a bad idea; it’s just that preventive care is rarely money-saving.
In addition, it’s not clear that many medical organizations believe our investments in primary care are inadequate. I talked to a young physician a few years ago and he said the pressure to specialize began early. Medical students are quietly discouraged from practicing primary care by their mentors and instructors. The American Medical Association (AMA) helped create relative value units (RVUs), a fee schedule used to compensate physicians who treat Medicare patients. The RVU fee schedule for primary care is lower than specialties, reflecting the lower value the AMA places on primary care compared to other specialties in medicine.
Single-payer health care is a rationing system. It essentially involves setting a budget for health care and limiting what the payer is willing to reimburse for various services. It also is a way to limit the types of services the health authority is willing to fund. Senator Sanders would have us believe health care providers are willing to work for less. It doesn’t work that way in any other market.