Yes, I want universal healthcare in America — but not through Medicare-for-all

If you're planning to vote for a Democratic candidate in the 2020 election because they back Medicare-for-all, you need to read this first

Studies show that when people who support Medicare-for-all hear about the details, a lot of them stop supporting it (Mark Makela/Getty Images)

In America, both Democrats and Republicans can agree on one thing about our healthcare system: it isn’t working.

Out of all developed countries, the United States spends the most on healthcare per capita — even countries like the UK which have a free national healthcare system. Yet there are still 28.5 million people that are uninsured and unable to get basic treatment. The lack of a cohesive health strategy may well have cost Republicans the House in the 2018 midterm elections, and there can be little doubt that healthcare reform for all Americans will be a primary focus of the 2020 presidential election.

Democratic candidate Senator Bernie Sanders has proposed a solution to our out-dated, dysfunctional healthcare reality — Medicare-for-all. This single-payer proposition is a dream to a generation of Democrats who believe that healthcare should be approached as a fundamental human right. Many Democratic voters — and the vast majority of people in the healthcare sector — would agree that they’d like to make universal health coverage happen. But it’s important to understand the difference between universal healthcare as a concept, and universal healthcare as it could be provided by Medicare-for-all.

Universal healthcare coverage would provide all Americans with some form of basic health insurance. It would require everyone to have a healthcare policy, but the government can decide if it wants to pay for that care entirely or pay for part of it and let others, such as commercial insurers, provide the rest.

Whether one’s insurance is entirely through a government-run program or partially through private insurance company, it doesn’t matter. Additionally, people would still pay taxes to the government to help fund Medicare, Medicaid, and the Veterans’ Administration.

Medicare-for-all would also require all Americans to get health insurance, but enrol only through the government, which is a single-payer system. Essentially, people would pay a varied premium to the government for their healthcare, rather than going through a third party such as a private insurance company.

On paper, Medicare-for-all might seem like the most effective way to go about solving our healthcare woes. In reality, there are many more complexities that prevent this from being the go-to solution. A study has even shown that once the possible implications of Medicare-for-all are explained, such as delayed medical treatments, increased taxes and changes to the current Medicare program, the majority of people oppose Medicare-for-all.

The truth is, if we were to elect Bernie Sanders, implement Medicare-for-all and abolish the private healthcare insurance industry, the United States would still pay too much for healthcare. Some projections predict that Medicare-for-all would cost the US over $30 trillion to implement. The only way to make sure every person in the US has healthcare insurance is to change how healthcare is paid for, not who pays for it.

Currently, in the United States, the primary payment mechanism for healthcare providers is called “fee-for-service”. Put simply, for each service a hospital or clinic provides, they are paid a fee for that particular service, hence the name.

In this system, the more patients a clinic or doctor provides services to, the more they earn. Currently in the US, providers are paid this “fee-for-service” by the federal government, commercial insurers and private, not-for-profit health plans.

Under today's fee-for-service system, commercial insurers, as well as the federal government, have tried to lower amounts paid to caregivers for each service because healthcare is only becoming more expensive in the United States, and it is thought the only way to solve the problem is to pay less. But this has consequences.

Caregivers rely on these fees for their earnings, so they can make a profit only by continuing to provide services to patients. If they don’t have enough earnings, they are forced to find more business elsewhere. This results in a never-ending quest to find more patients. The end result is more services (read: expense) at a time when we have more and more people in the US getting older and needing healthcare day by day.

An alternative and much more effective solution would be to flip the motives of caregivers. No longer should they be paid to do more testing and surgeries, but to keep people healthy with cheaper, preventative treatments.

This payment methodology, called capitation, results in caregivers being paid a smaller amount of money each month per patient assigned to them. The amount received each month is all the provider is paid to provide care for his or her capitated patients. As a result, the provider incentive becomes one of how to keep patients healthy, requiring fewer healthcare services over time.

The money that caregivers don’t spend on treatment is kept by the practice as profit. Essentially, the government would be giving caregivers an allowance, and the less they spend, the more they get to keep. This would reward healthcare providers for keeping their patients healthy, taking away any incentive to over-charge and over-treat.

Some may worry that this might encourage caregivers to not provide expensive treatments or necessary testing in order to pocket the money for themselves. But remember: if they don’t provide the necessary preventative treatments and tests in the first place, it is more likely that the patient will come back and cost them more money down the road. In a capitated system, that’s bad news.

Yes, a capitated payment system will require a lot of collaboration from various industries. But, it will work off our country’s pre-existing infrastructure, saving us much more time and money than if we were to abolish the private insurance industry under Medicare-for-all and implement a single-payer system.

This proposed payment plan isn’t nearly as sexy as Medicare-for-all, but it would be the most realistic way of making universal healthcare in America a reality.

If you believe healthcare is a basic human right, and want to make sure we can actually pay for it, we need to realize that Medicare-for-all isn’t the solution to fixing America’s healthcare system. How we pay health care providers is.