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  • Vikram Surya Chiruvolu

How could the US pay for universal healthcare? How could we not?


Well-known DC insight meditation teacher Hugh Byrne invited thoughtful responses in an FB post to CNN's Chris Cillizza calling Senator Sanders answer on how to pay for Medicare for All (MFA) 'disastrous'.


Senators Warren and Sanders' plans are a fair enough starting point to discuss how we pay for universal care, and there is plenty of room for reasonable people to disagree with him on various points of how they propose we pay for it. What does not much help is to conflate the question of whether we move forward with how—unfortunately, all the US Presidential candidates except Sanders and Warren are trying to insist on knowing the how first, and by poking holes in one idea of how or another, backpedal us on whether to do so.


The CNN headline Bernie Sanders' disastrous answer on '60 Minutes is perhaps effective clickbait, but it is anything but 'disastrous' for Senator Sanders to be humble and practical, and to say that we have some idea how we will pay initially, but that this will have such an enormous positive economic and social impact, we want to keep an open mind about how to evolve the payment model as that impact is felt. As the poor and middle class becomes less existentially threatened with death, bankruptcy, and foreclosure from healthcare costs, and enjoys greater wealth, we'll likely be able and willing to pay even more of the cost than the initial plan asks. The answer on the Sanders website does a fair job of spelling out programmatic details of how to organize socialized payment but it doesn't strongly enough make what we see as the key point: the US could see as much as a 50% or $2Tn/year saving in health costs under Medicare for All. A recent Lancet article it mentions puts the savings at $450Bn, but we think this is too conservative by not taking into account some important elements. Meanwhile, notably, the US national debt grew $1.3Tn last year.


Bernie's plan for universal care is similar to the plans already implemented in the UK, Canada, and Australia using a combination of payroll and property taxes. The average cost of healthcare as a percentage of national GDP in those three countries is about 9% whereas in the US it is 18%. We pay double, while having significantly lower, and declining, life expectancy.


Why does the US healthcare system cost twice as much as Canada, the UK, or Australia's without being universal? Because it's not universal!


When people get annual checkups and go to the doctor themselves because they're concerned about their health, they don't get as sick as often, and avoid burdening society with the costs of being taken to the hospital when they can't take themselves. Denying care by default, the approach of most private health insurers to anything beyond routine visits, then burdens society with litigating every claim. Canada, the UK, and Australia spend 50-75% less on administrative costs than the US, while all have higher life expectancies. Administration costs don't make people healthier, and they are a major factor in provider burnout, especially in community mental healthcare. As a provider, it can cost me as much time as a session to generate, issue and track the documentation to get paid for the session.


When children and the poor don't have health insurance, it doesn't change that providers still cannot ethically deny care in critical situations, so the system pays those costs regardless. Instead of a routine visit to a doctor, our system can pay 10 or 1000 times as much for a visit to the ER and related hospital stay. Instead of paying a few thousand dollars per year to everyone to have quality long-term mental health & substance use disorder care, we pay hundreds of thousands in acute care when there are accidents, attempted suicides, and overdoses. Even if a person is not insured, hospitals must then look to recoup the costs of the uninsured, and engage in across-the-board price inflation, according to this JAMA article from Harvard researchers, by padding the bills of other patients who are insured--which in turn makes insurers deny claims rightfully.


In the US, we over-rely on prescription drugs to such a degree that pharmaceutical companies have a stranglehold on high prices. Instead of clear-headed cost comparison between behavioral interventions like psychotherapy, health coaching, and digital app-based supports, versus pharmaceutical ones, we opt for the latter by default in many cases. Because changing behavior is seen as 'hard' by the medical profession, we ignore the dignity, empowerment, cost savings, reduced complications, and joy of behavioral interventions as a first-line intervention.


The reality of the "how will we pay for universal care" question is this: we're paying for it already, badly. Our present system is perhaps the worst possible way to organize providing care, trapping not just the poor in cycles of poverty, but our entire society.


An analogy: our present healthcare system works by denying people a glass of water— until they show up at the ER with their organs shutting down, needing intravenous rehydration. Because we have municipal water systems that have socialized the cost of drinkable water, we don't see this particular issue in most healthcare situations -- but we actually do organize care in this way with just about every other health condition for the uninsured.


If we socialize the cost of always-accessible healthcare, if similar nations like Canada, Australia, and the UK are any indication, we will spend radically less on it. The U.S. Constitution's Preamble states one of its main purposes is to “promote the general welfare". The lack of universal care is the biggest detriment to the general welfare we face on a day-to-day basis. We need to commit to it from a reasonable starting point, and then keep evolving to find the most balanced, fair, and sustainable ways to organize continuing to pay for it. Of necessity, this will involve a good deal of private sector creativity alongside government programs.


We at Technotherapy Public Benefit Corp., for example, are aiming to create a national behavioral health service reducing costs and increasing access to primary and specialty mental healthcare by providing it online. In the long run, those elements of the private sector interested in profiting and profiteering over the present systems' manifest dysfunction will not last. Wall Street knows this, and it explains the sharp plunge in public healthcare stocks after Senator Sanders' Nevada primary win. However, we believe organizations committed to providing quality health service to all, and responsibly socializing the wealth and well-being that universal care generates, will flourish.