Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.
Medicare for All Is Not Enough
March 31, 2022
By David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, John Geyman
We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.
However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.
But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.
These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.
Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?
In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.
Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.
Comment by: David Himmelstein & Steffie Woolhandler
Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.
But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physicians’ practices, hospitals, and other health care institutions. Avaricious firms — both for-profit and non-profit – are gobbling up the vital resources needed for care, gaming even traditional Medicare’s payment incentives, and prioritizing profitability over patients’ and communities’ needs. Physicians, like other health care personnel employed by these organizations, must either comply with executives’ profit-seeking directives or be shown the exit.
Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayers’ and patients’ dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotland’s National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.