The Affordable Care Act (ACA) provided oncology services to people with cancer who had previously been denied coverage. And for that reason alone, many oncologists supported its passage. However, even though the U.S. health-care system remains in the crosshairs of partisan politics, parties on both sides of the aisle agree that the health-care system is in need of work. The United States is the only major developed industrial country in the world without some form of universal health care, an idea that has been roundly dismissed.
James A. Morone, PhD
To shed light on the value of a “Medicare for All” system, The ASCO Post spoke with health-policy expert James A. Morone, PhD, the John Hazen White Professor of Public Policy and Professor of Political Science and Urban Studies at Brown University. He has written 10 critically acclaimed books and more than 150 articles, reviews, and essays on American political history, health-care policy, and social issues.
Difficulties in Navigating the American Political System
“Medicare for All” is far from a new idea. Please give us some context and share why you think the concept has faced such resistance.
The idea first came up during the New Deal, under Franklin Roosevelt, in 1935. President Roosevelt’s liberal advisors were eager for him to add health care to the new Social Security program, and, as World War II was coming to an end, he seemed to decide this would be his next great crusade. He had his most trusted aid draft a proposal—but he died just before the end of the war and the inexperienced Harry Truman took over. In President Truman’s first days in office, that proposal landed on his desk—it seemed to him like a final legacy of FDR, and President Truman pursued it with more passion than any other political issue in his life.
The checks and balances in the American system make it so hard to get things through Congress.— James A. Morone, PhD
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Why did it go nowhere? That’s easy: The checks and balances in the American system make it so hard to get things through Congress. President Truman ran on his national health insurance (NIH) bill in 1948 and won the election. If we were playing politics by English, Canadian, or French political rules, we would have had a single-payer National Health Institutes in 1949. The president would be expected to pass the program he ran on. But even though the issue propelled President Truman back into the White House, Southern Conservatives dominated Congress, and they blocked it.
This point is really worth stressing. It’s the way the American political system is organized—not the idea itself—that makes it so difficult.
Eventually, President Truman’s policy advisors suggested he cut back his NHI proposal to cover only people older than age 65. Once people saw how good it was, they said, it could be expanded. President Truman agreed in 1952. It still took more than a decade, but after the great landslide of 1964, Lyndon Johnson powered Medicare—single payer for people older than age 65—through Congress.
Notice the punch line. It’s not that people hate the government program. On the contrary, Medicare is very popular. It’s that our political system is set up in a way that makes getting big things through Congress difficult.
Positive Freedom vs Negative Freedom
In President Roosevelt’s speech on the Second Bill of Rights, he spoke about health care as a basic human right, which is another concept that bristles many. What are your thoughts on this?
President Roosevelt, who coined the term “liberal” for his type of approach, took a view of freedom that pretty much defines liberal attitudes today. It is called positive freedom and holds, that if you don’t have the basic necessities of life, freedom is meaningless: If you are sick, hungry, homeless, or being preyed on, you can’t truly be free, in this view. So, to truly have a free society, we provide the bare minimum to everyone: food for the hungry, health care for the sick, police protection against crime, education for all children. This view can be traced back to President Lincoln and his Gettysburg Address with its “new birth of freedom.”
The problem lies not in our medicine, which is quite good much of the time, but in the huge administrative apparatus that has grown up to process our chaotic nonsystem.— James A. Morone, PhD
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The alternative view, negative freedom, holds that freedom means the government must leave people alone. The government must not interfere with your rights to speak, pray, or bear arms.
The difference between positive freedom (provide the basics) and negative freedom (leave people alone) is the difference between liberal and conservative attitudes in the United States. Most other wealthy nations take a much more liberal view. Some people would argue that health care is a special case regardless of all this. Sooner or later, we will all need it. We will all get sick. They’d suggest that, since this is the human condition, every society ought to make sure that everyone can receive decent health care. Almost every developed nation takes this point of view.
Reducing Costs Without Harming Quality
Our $3-trillion system is moving toward insolvency. Could a Medicare for All system reduce costs and the huge administrative burdens without harming quality?
As payers of health care, we complain about the insolvency of the system. But remember, every dollar we spend on health care is a dollar of income to someone providing health care, America’s largest industry. Is health spending a terrible problem? That depends on whether you’re paying that dollar or taking it in.
But to answer the question, my favorite study on this subject was very simple. A policy analyst at the University of Minnesota went to a large hospital in Ontario and asked about “the billing department.” He was introduced to the four people in “billing.”
Every parent with a sick child and every adult with a hurting parent ought to be able to access the health‑care system regardless of whether they are rich or poor.— James A. Morone, PhD
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He then went to a similar-sized hospital in the Detroit area. There was a whole large area of the hospital with some 125 employees all in “billing.” Some sent bills to private insurance companies, others to the fiscal agents of the government programs, and still others were trying to collect payment from individuals who had been in the hospital. All those people in billing have counterparts at all the insurance companies and government programs and doctors’ offices.
Now, advocates of a single payer say, if you could get rid of all those people chasing all those payments, you’d save a huge amount of money (some enthusiastic advocates claim it could be one-fifth of all health-care costs). And you would probably improve the quality of care because providers wouldn’t be spending so much time justifying what they did to insurers and chasing insurers and patients looking to be paid. The problem lies not in our medicine, which is quite good much of the time, but in the huge administrative apparatus that has grown up to process our chaotic nonsystem.
A More Sensible Place
Our payment system isn’t compatible with a Medicare for All system. Is it feasible to think we could come up with an alternate payment model to satisfy all stakeholders?
There are a lot of people who profit from the current system. Most of them are in the financial end and not the medical end. We can’t solve the problem and satisfy all stakeholders. Instead, we should start at a more sensible place: Ask how can we make health care better for the population? Or, to put the question more pointedly, how can we improve terrible outcomes data? Our life expectancy at birth ranks something like 40th in the world (depending on the study). It is crazy for a wealthy nation to spend almost 20 cents on each dollar for health care.
We should start with the best system possible and then figure out how to get it through the stakeholders. Medicare for All advocates think they have the best and simplest system. Their thinking is start a movement that will help push the politics.
Basic Human Value
In short, what is the most persuasive argument for a Medicare for All system?
Simple fairness. Every parent with a sick child and every adult with a hurting parent ought to be able to access the health-care system regardless of whether they are rich or poor. It’s a basic value, something that ought to tie us together as fellow citizens, as fellow humans. Remember, we are all going to get sick and die. This is a basic human value. Ironically, watching out for one another in this decent way will almost certainly make for a much better health-care system. ■
DISCLOSURE: Dr. Morone reported no conflicts of interest.