Great Britain got such a system in 1946, after voters shocked the world by defeating Winston Churchill, and replacing him with a Labor prime minister. Canada authorized its national system — called Medicare — in 1966, two decades after provincial Premier Tommy Douglas did it in Saskatchewan.
Alone among “English speaking peoples,” as Churchill called them — and the entire developed world — the United States doesn’t guarantee access to a national system with no consumer billing. The consequences, in lives lost, disrupted and impoverished — along with billions of dollars wasted every year — are almost incalculable.
But now, with our vaunted health care system performing dismally amid coronavirus, and a progressive wave crest building, there may finally be a chance to right this wrong.
What we did get, concurrently with Canada, was our version of Medicare, along with Medicaid. People still confuse the names. As a young reporter, I was taught: “Medicare for old people, Medicaid for poor people,” and that’s still reasonably accurate.
The vast middle was then covered by comprehensive, employer-paid private plans. The collapse of that system brought us our current crisis.
Now, as an enrollee in our only true “single payer” system — along with another huge cohort of “baby boomers,” at a surprisingly youthful age — I’m studying the system’s many peculiarities.
For example, the Part B premiums covering doctor visits rise steadily, and are now $144.60 per month, up 6.7% from 2019. But Advantage plans, accessing some unbelievably expensive medical procedures and prescription benefits — albeit with co-pays and deductibles — cost $29 or less.
It’s very odd. We penalize seniors for seeing the doctor, who might diagnose a problem before it’s serious or chronic, while giving carte blanche to specialists who find many ways to spend government dollars.
Here’s an actual office visit: Fee, $72, divided as follows: Co-pay, Medicare recipient, $40; government payment, $10.05; write-off by doctor, $21.95. I defy anyone to explain the economic logic. Despite Medicare insurance, the patient pays 80%.
So before we decide that simply extending Medicare, and Medicaid, is the answer, we must dig more deeply into the curious, almost unknown, story of how Medicare came to be.
For those who remember, Medicare is linked to Lyndon Johnson’s “Great Society” legislation featuring the Civil Rights and Voting Rights acts. Yet Johnson never asked Congress for Medicare; his limited aim was “pre-paid hospital care” to prevent bankruptcy among working class Americans.
It resembled legislation advocated by Earl Warren, Republican governor of California, way back in 1941, who — before becoming perhaps the nation’s greatest Chief Justice — forged the most progressive state government in the land. His own party blocked the hospital initiative, but it remained a beachhead for reform.
The 1965 Medicare legislation was the work of Wilbur Mills, the cantankerous chairman of the House Ways and Means Committee — ordinarily death on spending bills, but intrigued by the technical challenge of national health care.
Doctors, outraged over government “controlling” them by paying hospital bills — these were dark days for the American Medical Association — crafted a bill, intended to block Johnson’s. It covered office visits — today’s Part B.
Republicans decided only poor people needed coverage — who could then be stigmatized, much as today’s Medicaid recipients often are. Reimbursements in this state-federal program are much lower than Medicare, or private insurance.
Instead of legislative gridlock, Mills had the amazing notion of putting all three concepts together, and Medicare/Medicaid proved irresistible to a briefly reform-minded Congress. Retrenchment followed, as Vietnam destroyed Johnson’s presidency, but the new programs proved impossible to dislodge.
As a template for national coverage, however, Medicare and Medicaid are flawed. Part B’s meager financing stems from the AMA’s fervent opposition: Doctors got less; hospitals, too much. Advantage plans represent Democrats’ later abandonment of a fully public program; a Republican Congress, under President George W. Bush, offered a prescription coverage deal in 2003.
Before Medicare or Medicaid can become models for further expansion — the Affordable Care Act’s approach — they should be overhauled to create positive incentives, not perverse ones.
Payments must focus on keeping people healthy. Co-pays, if any, need to be low, so everyone gets care. Drug prices have to be controlled, and private Advantage plans phased out.
It will take lots of constructive, detailed work by Congress — the kind of work our representatives seemingly have forgotten how to do.
We need patience, but not infinite patience. Before the next Congress adjourns, we must have a pathway to national health comparable to the world’s best.
If it seems too hard, just imagine what it will be like when the next pandemic looms on the horizon.
Douglas Rooks, a Maine editor, reporter, opinion writer and author for 35 years, has published books about George Mitchell, and the Maine Democratic Party. He welcomes comment at: drooks@tds.net
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