It’s very likely1 that I won’t have to convince you, dear reader, that America’s healthcare system is fucked. Healthcare is the “most important” issue in the 2020 election for 36% of Democratic voters, 30% of independent voters, 28% of swing voters and 17% of Republicans. Many Americans think it deserves a complete overhaul and over half the American electorate favors its replacement with single payer Medicare for All (M4A).2

Everyone I know has at least one health insurance horror story or has faced a long protracted battle to receive medical care. To save money, I’ve anxiously skipped prescribed cancer screenings, blood tests and follow up appointments. Who hasn’t? As a tiny cog in America’s healthcare machine, I’ve been watching the popularity of M4A grow with subdued excitement.

A few weeks ago my friend Jill asked me how Bernie Sanders’s M4A plan differed from Elizabeth Warren’s M4A plan. To impress her before Super Tuesday, I have reviewed the material available on the two candidates’ websites to answer these burning questions3:

  • What exactly is offered by Bernie Sanders’s Medicare for All Act of 2019?
  • By supporting M4A, does Elizabeth Warren support the Medicare for All Act of 2019? If not does she support another bill? Does she have a plan of her own?
  • Which candidate’s plan is more comprehensive and/or from my layperson’s understanding of how healthcare works in this country, which do I think is most worth fighting for.

Sing in me O Jill, and through me tell the story
of that person skilled in all ways of contending,
the wanderer, harried for years on end,
the American patient

An Overview of Healthcare in the U.S.

There is a ton of research quantifying how the American healthcare system is uniquely, bureaucratic, inefficient, expensive and cruel. Before we discuss what the two candidates have to offer us, here are some studies to consider:

Compared with citizens in other wealthy nations, Americans do not have access to preventative care.

  • Out of 16 high income, industrialized countries, the United States experiences the highest rate of deaths that could have been prevented by timely access to healthcare.4
  • A comprehensive review of studies, published in Annals of Internal Medicine, suggests that thousands of Americans die each year because they don’t have health insurance.5

Healthcare in the United States is rationed according to race.

  • According to a 2017 Gallup poll, 29% of hispanic Americans, 12.5% of black Americans and 6.9% of white Americans do not have health insurance. In total, 12.2% of Americans who do not have health insurance.6
  • Black infants in the United States are twice as likely to die as white infants. From a NYT article on a study by the Brookings institute, that is “11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data — a racial disparity that is actually wider than in 1850, 15 years before the end of slavery, when most black women were considered chattel. In one year, that racial gap adds up to more than 4,000 lost black babies.”7

The U.S. is a uniquely dangerous place for newborns, pregnant people, and the elderly.

  • In general, the infant mortality rate in the United States is higher than some of its closest neighbors with 5.6 per 1,000 infants dying in the U.S. versus8 3.7 per 1,000 in Canada and 4.3 per 1,000 in Cuba.9
  • The United States has the highest maternal mortality rate in the developed world. American women are more than three times as likely as Canadian women and more than six times as likely as Scandinavian women to die in the maternal period. A recent analysis by the CDC found that maternal deaths increased from 2000 to 2014 and that nearly 60 percent of such deaths were preventable. 10
  • Despite near-universal coverage through Medicare, 23% of older adults in the U.S. reported that they had not visited a doctor when sick, had skipped a recommended test or treatment, had not filled a prescription, or had skipped medication doses because of the cost in the past year. 5% or fewer of respondents in France, Norway, Sweden, and the U.K. reported these cost barriers.11

The U.S. healthcare system can lead to bad outcomes for a majority of Americans living with chronic conditions.

  • 60% of American adults now live with at least one chronic condition.12 I couldn’t find data on how many Americans have chronic conditions that are often preventable, such as type 2 diabetes, asthma, heart disease and chronic lung disease.
  • People with chronic conditions use over 75% of hospital stays, office visits, home health care and prescription drug usage. Currently, 85% of healthcare spending is devoted to managing chronic conditions.13 Who can say how many of these expenditures or more importantly, negative patient outcomes, could be avoided by preventative care?

On average, patients in the U.S. pay more for healthcare and suffer worse health outcomes.

  • Despite having similar utilization rates, the U.S. spends about $10,600 per person on healthcare, nearly twice as much as other wealthy countries and the highest across all OECD countries. The average for wealthy OECD countries, excluding the United States, is only $5,300 per person.14
  • According to the 2019 Milliman Medical Index, the cost of healthcare for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $28,386.15
  • For more information about what drives healthcare costs in the U.S., please read Tim Faust’s Health Justice Now.16

Medical bankruptcy is the leading cause of bankruptcy in the U.S.

  • A 2019 study found that 66.5% of all bankruptcies in the U.S. were tied to medical issues, either from medical costs or loss of income due to illness.17 According to the CFPB, medical debt was the most common reason for someone to be contacted by a debt collector.18
  • According to a 2019 Gallup poll, 45% of American adults fear a major health event will leave them bankrupt.19 A 2018 Gallup poll found that an average 30% of American adults put off healthcare each year due to cost.20
  • A 2018 study found that 35% of adults ages 19-64 had a medical problem but did not visit a doctor or clinic, did not fill a prescription, skipped a recommended test, treatment or follow-up and/or did not get needed specialist care because of cost.21
  • A 2019 study in the Journal of General Internal Medicine, 95% of American adults have reported medical financial hardship in the past year.22

A Primer on Insurance

There are two types of insurance in the United States, public insurance paid for by public money, i.e. Medicaid, Medicare, Veterans Affairs or the Indian Health Service, and private insurance, which is subsidized by public money and can be purchased through one’s employer or directly from the insurer on the individual insurance market.

The business model of private insurers is straightforward: pay out less for medical care than they take in as premiums.

To do that, insurance companies create a pool of money – called a risk pool because it pools the collective risk that any given customer will require expensive medical care across a large number of inexpensive customers – by collecting premiums from as many healthy customers as possible. If too many people with chronic conditions sign up for insurance, the insurer’s per-person costs increase and the insurer must compensate by increasing premiums. Often when premiums increase, people who can’t afford those premiums drop out and the insurer’s cost per-person continues to increase.

To stop this cycle, insurers drop coverage for drugs and care needed by expensive, i.e. sick people, coercing those people into dropping out or switching insurance. Some examples:

  • In Florida and Illinois, insurance companies are being sued for intentionally making it difficult for people with HIV/AIDS to get the drugs they need. The suit alleges that this is so people with diseases will go to other insurance companies.23
  • Ever wonder why it’s impossible to get insurance to cover mental healthcare? Because mental disorders and mental illness are most often chronic conditions, and can often involve expensive hospitalizations, it is not profitable to cover people who have them.24
  • Insurers, who may only cover individuals for a few years of their lives, see investments in long-term health as a cost they’ll never recoup - so they have a financial incentive to deny patients these treatments.

Perversely, insurance companies make money only when the people they insure do not use their insurance plan. Currently the government provides public insurance (Medicare), to the elderly, a large group of Americans who are very costly to insure, taking them off the private market. Despite this boon, insurance companies are struggling to keep up with the rising cost of healthcare and working Americans have seen premium increases alone outpace their wage growth.25

What is Medicare for All?

Typically, M4A refers to a single payer healthcare system in which the government provides universal healthcare coverage for its citizens. Generally M4A is conceived of as like Medicare (the most popular healthcare program in the country), but with dental, mental, vision and long term care and without cost sharing, i.e. premiums or deductables. I see four huge ways in which M4A would create cheaper and better healthcare:

  1. Health Justice and Bonus Risk Pool Party. If all Americans had access to free healthcare, they would no longer worry that a car accident, pregnancy, or chronic condition might bankrupt them; they would be free to change jobs without fear of loosing their healthcare; and they would be significantly less likely to die an easily preventable death. Similar to popular programs like Medicare and Social Security, all Americans would benefit from universal health coverage, so all Americans would fight for it. Also, if all Americans are part of the same risk pool, there is no incentive to avoid providing services for people who are chronically sick. In fact, the federal government would have more incentive to fix public health crises like the ongoing 2014 Flint water crisis.
  2. End of a Bureaucratic Nightmare. Doctors and nurses currently spend a significant part of their day filling out forms and arguing with insurance companies. With single payer, healthcare professionals could spend more time taking care of patients. As an added bonus, some experts estimate that we would save up to $500 billion annually in administrative costs. 26
  3. Economies of Scale. Private insurance companies don’t have the same kind of scale that Medicare, or even a state Medicaid plan has, so they don’t have much leverage to negotiate down healthcare costs with hospitals and drug companies. Medicare spends a fifth of total national healthcare dollars and insures 15% of the nation’s population, making it by far the largest insurer in the United States. Each year Medicare determines how much it will pay for services, and if hospitals choose to reject those prices they will loose 44 million customers with guaranteed payment. As a result the vast majority of hospitals and nine out of ten primary care physicians take Medicare patients.27 If all American’s healthcare costs were negotiated by a single payer, experts estimate we would save up to $113 billion annually from prescription drugs costs alone.28 Why are drug costs so low in countries such as Sweden? Because the government of those countries set drug prices for the entire marketplace.29
  4. Better for Workers and Employers. Employers would be free to focus on running their business instead of spending countless hours figuring out how to provide health insurance to their employees. Employees wouldn’t have to choose between bargaining for higher wages or better health insurance.

From the February 2020 issue of The Lancet:

“Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than $450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.”30

The Plans

Now, with a renewed sense of urgency, let’s see what the two progressive candidates are proposing to address this life or death situation:

The Elizabeth Warren Plan

Warren has effectively proposed two plans: what amounts to a substantial Medicaid/Medicare expansion within her first 100 days and a transition to the full single payer system defined by Bernie Sanders’s Medicare for All Act by the end of her term. Here is the timeline described on her website:

Day One

  • Protect people with pre-existing conditions by defending the Affordable Care Act
  • Reverse the Trump administration’s sabotage of our health care system
  • Lower costs of key drugs for millions of Americans, including insulin, EpiPens, and HIV drugs

Within Her First 100 Days

  • Provide a public health insurance option that is completely free for children under 18 and families under double the poverty level (that’s equivalent to making $51,000/year for a family of four) and available to everyone else at a modest cost.
  • Lower the age of eligibility for Medicare to 50, while improving the program to include dental and vision, long term care, and significantly lower cost sharing.

Within Her First Three Years

  • Push Congress to pass legislation to complete the transition to Medicare for All as defined by Bernie Sanders’s Medicare for All Act of 2019 and provide free health care which includes vision, hearing, dental, mental health, and long-term care for every person in the country.
  • Push to strengthen the National Suicide Prevention Lifeline to better serve at-risk populations, like LGBTQ+ youth.
  • Move to publicly manufacture PrEP.

Her Plan to Lower Drug Prices

  • Leverage excise taxes to negotiate prices for both branded and generic drugs, with no drug exceeding 110% of the average international market price, but remove the limit of the number of drugs Medicare can negotiate for and eliminate the “target price” so Medicare could potentially negotiate prices lower than other countries.
  • Override drug patents, as modeled in the Medicare Negotiation and Competitive Licensing Act.
  • Publicly manufacture certain drugs, as modeled in the Affordable Drug Manufacturing Act.

Financing

  • No middle class tax increases.
  • Collect money companies normally send private insurance companies in the form of an Employer Medicare Contribution. Small businesses – companies with under 50 employees – would be exempt from this requirement if they aren’t paying for employee health care today. This will generate almost half of what is required to cover Medicare for All.
  • Invest in stronger enforcement and adopt best practices on tax reporting, withholding, and filing, experts predict that we can close the tax gap by a third – generating about $2.3 trillion in additional federal revenue without a single new tax.
  • Various wealth taxes: a small tax on financial transactions – one-tenth of one percent on the sale of bonds, stocks, or derivatives; a country-by-country minimum tax on foreign earnings of 35% – equal to a restored top corporate tax rate for U.S. firms – without permitting corporations to defer those payments; and finally a six cent tax on each dollar of net worth above $1 billion.

The Bernie Sanders Plan

Bernie pledges to immediately fight for a single-payer, national health insurance program to provide everyone in America with comprehensive health care coverage, free at the point of service with no networks, no premiums, no deductibles, and no copays. Medicare coverage will be expanded and improved to include dental, hearing, vision, and home and community-based long-term care, in-patient and out-patient services, mental health and substance abuse treatment, reproductive and maternity care, prescription drugs, and more. In its LGBTQ+ section, Bernie’s website emphasizes that M4A would also cover gender affirming surgeries, increase access to PrEP, remove barriers to mental health care and bolster suicide prevention efforts.

His Plan to Lower Drug Costs

  • No out of pocket spending on health aside from prescription drugs. This cost is capped at $200 a year.
  • Cut prescription drug prices in half, with the Prescription Drug Price Relief Act, by pegging prices to the median drug price in five major countries: Canada, the United Kingdom, France, Germany, and Japan.
  • Allow Medicare to negotiate with the big drug companies to lower prescription drug prices with the Medicare Drug Price Negotiation Act.
  • Allow patients, pharmacists, and wholesalers to buy low-cost prescription drugs from Canada and other industrialized countries with the Affordable and Safe Prescription Drug Importation Act.

His Plan to Eliminate Medical Debt

  • Eliminate all of the $81 billion in past-due medical debt held by 79 million Americans. It is fully paid for by establishing an income inequality tax on large corporations that pay CEOs at least 50 times more than average workers.
  • Reform bankruptcy laws to use the existing bankruptcy court system to provide relief for those with burdensome medical debt.
  • Create a secure public credit registry to replace for-profit credit reporting agencies.

Financing

  • a 4% income-based premium paid by employees, exempting the first $29,000 in income for a family of four.
  • a 7.5% income-based premium paid by employers, exempting the first $1 million in payroll to protect small businesses.
  • Eliminating health tax expenditures, which would no longer be needed under Medicare for All.
  • Raising the top marginal income tax rate to 52% on income over $10 million.
  • Replacing the cap on the state and local tax deduction with an overall dollar cap of $50,000 for a married couple on all itemized deductions.
  • Taxing capital gains at the same rates as income from wages and cracking down on gaming through derivatives, like-kind exchanges, and the zero tax rate on capital gains passed on through bequests.
  • Enacting the For the 99.8% Act, which returns the estate tax exemption to the 2009 level of $3.5 million, closes egregious loopholes, and increases rates progressively including by adding a top tax rate of 77% on estate values in excess of $1 billion.
  • Enacting corporate tax reform including restoring the top federal corporate income tax rate to 35%.
  • Using $350 billion of the amount raised from the tax on extreme wealth to help finance Medicare for All.

I did not read the entire Medicare For All Act of 2019, but you can.31

My Analysis

Overall, the two plans reflect the two candidate’s divergent interests. I would say that Bernie has made M4A the focal point of his campaign platform, while Warren has focused more on anti-corruption. When comparing Bernie’s plan to Warren’s second plan, Bernie’s plan is more ambitious as it explicitly includes transition-related procedures and a plan to provide relief to the tens of millions of Americans in medical debt. Warren’s first year plan is not, by the standards outlined above, a single payer plan, but does provide a public option.

Both candidates have detailed and credible plans for how they will finance M4A, although Bernie’s budget is more broad and simple, befitting his more ambitious implementation. Warren promises not to raise taxes on the middle class while Bernie does not, instead making the case that a middle class will net save thousands of dollars on annual healthcare costs with his plan.

Given the broader benefits of Bernie’s plan, I favor it to Warren’s second plan. I am also extremely skeptical of Warren’s two plans.

Currently there is a lot of political enthusiasm for M4A. It will only pass if Warren or Bernie wins and a wave of newly elected Democrat Congress members flips the majority Republican Senate. In Warren’s current proposal, she will spend all of that political capitol legislating and implementing her first public option plan. However, if Republicans take back the House in the mid terms, as they did after Obama passed the ACA, she will no longer be able to pass single payer M4A legislation and all that early political enthusiasm will have been squandered.

Her first plan risks being less popular than Bernie’s plan and even less cost effective. How can she guarantee costs to patients will be “modest”? What do “modest” costs mean? What if the public option ends up costing more than private insurance and there’s not a big enough group of people on it for the government effectively bargain with hospitals and drug companies? Since it doesn’t have the universal impact of a single payer plan, it won’t rally the same number of voters to defend it.

Medicare for All can only be accomplished by a massive movement, by the vast majority of Americans suffering under a cruel, dysfunctional healthcare system. If we don’t force our members of Congress to pass M4A, it won’t happen, no matter how competent the executive pushing for it. For M4A to pass, Americans need to be galvanized by the possibility of health justice. The 50% of Americans who will not be affected by Warren’s initial Medicaid expansion and Medicare improvements are more likely to rally for and defend free healthcare than modestly priced healthcare.

Because it is difficult to sustain the energy of mass movements, it makes more sense to start negotiating with the most ambitious M4A plan when political will is at its highest. The role of the president is to set a vision for people to rally behind and demand their legislators put into action. I think Bernie has set the most compelling vision for what healthcare justice could look like in this country, now it’s up to us to make it happen.

Footnotes

  1. https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-february-2020/ 

  2. https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-february-2020/ 

  3. I realize that seriously considering a politician’s stated platform seems foolish because there is no guarantee that they will accomplish or even remain consistent on what they promise their supporters. But to pass a massive change like M4A, a massive group of people must be inspired by a vision of a future that is worth giving up their precious free time to organize with like-minded strangers. So reviewing the plan that a candidate is asking us to fight for is very important. 

  4. https://www.commonwealthfund.org/publications/newsletter-article/new-study-us-last-among-wealthy-nations-preventable-deaths 

  5. https://annals.org/aim/fullarticle/2635326/relationship-health-insurance-mortality-lack-insurance-deadly 

  6. https://news.gallup.com/poll/225383/uninsured-rate-steady-fourth-quarter-2017.aspx 

  7. https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html 

  8. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm 

  9. https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=CU-US-CA 

  10. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system 

  11. https://www.commonwealthfund.org/publications/journal-article/2017/nov/older-americans-were-sicker-and-faced-more-financial-barriers 

  12. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.html 

  13. https://www.rwjf.org/en/library/research/2010/01/chronic-care.html 

  14. https://www.pgpf.org/blog/2019/07/how-does-the-us-healthcare-system-compare-to-other-countries 

  15. https://www.milliman.com/insight/2019-Milliman-Medical-Index 

  16. https://www.mhpbooks.com/books/health-justice-now/ 

  17. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304901?journalCode=ajph 

  18. https://www.theatlantic.com/business/archive/2017/06/medical-bills/530679/ 

  19. https://news.gallup.com/opinion/gallup/248108/americans-fear-personal-national-healthcare-cost-crisis.aspx 

  20. https://news.gallup.com/poll/245486/delaying-care-healthcare-strategy-three-americans.aspx?g_source=link_NEWSV9&g_medium=TOPIC&g_campaign=item_&g_content=Delaying%2520Care%2520a%2520Healthcare%2520Strategy%2520for%2520Three%2520in%252010%2520Americans 

  21. https://www.commonwealthfund.org/sites/default/files/2019-02/Collins_hlt_ins_coverage_8_years_after_ACA_2018_biennial_survey_sb.pdf 

  22. https://link.springer.com/article/10.1007/s11606-019-05002-w 

  23. https://www.healthline.com/health-news/lawsuit-accuses-insurers-withholding-hiv-medication-053014#1, this example is copped from Tim Faust’s Health Justice Now 

  24. https://www.researchgate.net/publication/7375514Why_we_must_end_insurance_discrimination_against_mental_health_care this example is also copped from Tim Faust’s _Health Justice Now 

  25. https://www.kff.org/health-costs/report/2019-employer-health-benefits-survey/ 

  26. https://annals.org/data/Journals/AIM/936177/M170302tt1_Table_Estimated_Administrative_and_Prescription_Drug_Savings_Under_Single-Payer_Refor.jpeg 

  27. https://www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/ 

  28. https://annals.org/data/Journals/AIM/936177/M170302tt1_Table_Estimated_Administrative_and_Prescription_Drug_Savings_Under_Single-Payer_Refor.jpeg 

  29. https://phhp-bahealthscience-new.sites.medinfo.ufl.edu/files/2016/09/jsc1600151.pdf 

  30. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33019-3/fulltext#%20 

  31. https://www.congress.gov/bill/116th-congress/senate-bill/1129/text