The Problem The Universal Health Care System Solution
Despite Medicaid and the Affordable Care Act, nearly half of Americans aged 19 to 64, including many Maine residents, remain un- or under-insured. The number of unemployed in Maine has doubled during the COVID-19 pandemic, meaning loss of health insurance for many workers. Short term or “junk” plans are being promoted as the ACA is being attacked. Lack of adequate health care coverage has been shown to increase mortality. In a public system, health care is considered a government responsibility: in most Maine state proposals, Rep. Brooks’ Act to Support Universal Health Care  and the model offered in the Maine Center for Economic Policy’s Assessing the Costs and Impacts of a State-Level Single-Payer Health Care System in Maine, the state would ensure that all residents are covered by either an existing federal or federal-state program or its Maine state plan. Health care coverage has been shown to benefit the economic status of individuals and families as well as their health.
The Problem The Universal Health Care System Solution
Health care costs are rising faster than the general inflation rate, causing financial stress for individuals, businesses, municipalities, and the country at large. Private health insurance costs per enrollee have gone up twice as fast as Medicare’s. The takeover of government plans (Medicare Advantage, Medicaid Managed Care, Medicare Part D, supplemental policies) by commercial insurance has added middleman costs. Venture capitalists buy up physician practices, adding more middleman costs. The “competition” once thought to control cost has not done so, as health care does not function as a traditional commodity in a classic market. Provider reimbursement negotiation, along with global budgets for hospitals, help control costs. Elimination of the commercial insurance middleman reduces costly waste. A recent review of Medicare for All cost studies has shown average annual savings of over 5%, while a separate review of analyses of national and state “single-payer” systems has found savings as well. Of particular interest are studies of Minnesota, New York, and Maine proposals.
High prices of some drugs are a special case: true drug costs are hidden in negotiations among insurers, pharmacy benefit managers, pharmaceutical companies, and pharmacies. PBM administrative functions, manufacturer rebates, “price spreading,” and “clawbacks” (copays) all help drive price increases. Drug companies often charge “what the market will bear,” as in the case of Remdesivir  or Daraprim. Drug makers lobby congress heavily to prevent efforts to control prices, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 prevents the government from negotiating drug prices for Medicare. In most universal health care proposals, evidence-based formularies are established, generics are emphasized, and drug prices are negotiated.
The Problem The Universal Health Care System Solution
In general, employees pay a greater proportion of their income for health care than better-paid employers and executives do (poll tax phenomenon). Two thirds of US health care is paid for by taxes, and the tax on “labor income” is higher than the tax on “capital income.” Funding through income-based taxes spreads the cost of care equitably.
Workers never know their true health care costs, which are paid in part through unknowable reductions in wages and other benefits. Health care costs are transparent, predictable, and controllable in a public system.
Workers are held hostage to health care access in labor negotiations and are leery of changing jobs or becoming entrepreneurs themselves for fear of losing their health care coverage (job lock). On average, workers change jobs twelve times by age 50, meaning twelve changes of health insurance. Health care issues were one of the factors leading to the Bath Iron Works strike of 2020. With health care delinked from employment, workers can focus labor negotiations on more pertinent workplace issues and make their own life decisions more freely.
Workers are dependent on employers for the types of health care, for example birth control, that will be covered in their plan. In a public plan, coverage decisions will be based on medical consensus, not employer ideology; and subject to the democratic process.
The multitude of coverage, formulary, and cost-sharing (copays, deductibles, co-insurance, out-of-pocket maximums) schemes can be confusing to workers. When coverage is lost, Medicaid, Marketplace, and COBRA options can be confusing as well. A public plan’s simplified system replacing multiple plans for over half the population means everyone will have a straightforward, familiar plan.
Sixty-one percent of U.S. employees with employer-sponsored health insurance are in self-insured plans, which do not require coverage of the essential health benefits designated in the Affordable Care Act or a cap on older enrollees’ premiums. Comprehensive benefits are included for all people enrolled in public plans.
The Problem The Universal Health Care System Solution
Presently we have a medical class system: those “deserving” good care (workers, elderly, veterans, etc.) and those not (the poor, unemployed, able-bodied young, etc.). A Medicaid stigma can be felt by enrollees, the public, and providers, impeding quality of care. In a health care system that covers everyone, health care is considered a public good, not a privilege: all citizens are treated equally, just as they are in the case of national defense and access to clean water.
Presently we have a racially biased health care system: African-Americans suffer more from disease than do whites, and 11% of African-Americans are uninsured vs. 8% of whites. Industry-wide commercial prediction algorithms reduce health care for African-Americans vs. whites. Public support for Medicaid expansion has been racialized, to the detriment of African-Americans’ health care.
The Problem The Universal Health Care System Solution
The complexity of a multi-payer system, coexisting with a large block of people outside the health care system, impedes the response to a national or state health crisis like the COVID-19 pandemic. In a universal system, comprehensive patient, provider, and resource data would be maintained and lines of communication with all parties would have been established, allowing for evidence-based, coordinated, and prompt responses.
The Problem The Universal Health Care System Solution
U.S. health outcomes are worse than those of other industrialized countries. In a universal health care system, shortcomings can be identified and corrected: health is the ultimate goal of the system, not profit.
Out of pocket costs discourage use of preventive as well as therapeutic care. High deductibles are associated with barriers to care for cancer survivors, especially for African-Americans. With “pre-paid” care, care can be accessed when needed, not just when affordable.
Primary care has become less available as a result of higher reimbursement and profitability of specialty care, resulting in less emphasis on the prevention and long-term doctor-patient relationships provided in primary care. In universal health care systems, primary care is prioritized, mainly through improved reimbursement.
Important components of health like vision, hearing, and dental care are not covered in many commercial and existing public plans, leading to inappropriate and expensive emergency room visits, not to mention neglected care. Vision, hearing, and dental care are usually features of universal health care plans.
For those with commercial insurance, narrow networks of providers limit patient choice and can force change of provider whenever the employer changes plan or worker changes job. Some physicians selectively avoid Medicaid patients because of lower reimbursement and other factors, limiting choice for those patients. In a public system, most providers participate, giving all patients broad choice of physician, test center, and hospital.
The bewildering array of commercial plans available to individuals not assigned one through employment makes plan selection difficult. One third of such individuals change plans annually. In a public system, good health care is made available to all: no one has to spend time studying plans or risk choosing the wrong one.
The Problem The Universal Health Care System Solution
Employers are saddled with health care responsibility and costs (7.5% of employee compensation on average), or are at a hiring disadvantage if they can’t afford to offer the benefit. Many employers are convinced to “self-insure,” agreeing to “administrative services only contracts” that increase their risk and need for health economics sophistication they don’t always have. Warren Buffett: “medical costs are the tapeworm of American economic competitiveness.” When government is responsible for health care funding, and that funding is spread out equitably across the population, employers’ health care costs and administrative responsibilities can be reduced,     allowing them to devote the time and resources saved to developing their business.
Employers risk employee dissatisfaction and even strikes over health benefit features. Without responsibility for health care, companies avoid the risk of morale problems and strikes over the issue.
The Problem The Universal Health Care System Solution
Physicians are forced to spend time determining what is covered in patients’ various plans (tests, consultants, drugs and other therapies) and in unique documentation for the various payers. Denial and approval decisions are often left to nonmedical insurance company employees, appeal of which can be difficult and time-consuming for patient and provider alike. These diversions from patient care are among the causes of physician burnout. Because the goal of publicly funded universal health care is simply good health rather than the payer’s profit, medical decisions are largely left to providers and their patients. Documentation is standardized and simplified. As with any system, of course, some oversight will be necessary.
Health care professionals face the moral dilemma of either the financial risk of providing charity care or the guilt of turning patients away, a dilemma for which their medical education does not prepare them. In universal health care plans, equivalent reimbursement is guaranteed for all patients.
Physicians and hospitals have to support large billing and collections departments, computer systems, and consultants, to keep up with multiple, everchanging payers and plans. In a simplified, stable system, large billing departments are not necessary. Operating expenses fall, compensating somewhat for any reduced reimbursement.
Hospitals have to deal with uncompensated care, which forces them sometimes to promote activities that pay well (orthopedic and cardiac surgery), to scale back ones that don’t (diabetes, mental health care), to discourage Medicaid patients, or even close. In most universal health care plans, hospitals operate under global operating budgets separate from capital budgets and based on community needs. Support of hospitals, including rural ones, is a priority.
In the present system, health care professionals are burdened with unnecessary costs. A) Malpractice insurance premiums now include coverage for “medical special damages” (health care costs resulting from malpractice). B) Professionals have to pay for their and their staff’s health insurance. In a universal health care system, practice overhead would be reduced. A) The part of the malpractice premium covering “medical special damages” would be eliminated as the claimant’s health care would already be covered. B) Health insurance would no longer be a practice responsibility. (There would, of course, be some health care cost to professionals as employers.)
The Problem The Universal Health Care System Solution
The exclusion from income and payroll taxes of employer and employee contributions for employer-sponsored insurance reduces federal tax revenue by over $250 billion a year, much of which must still be raised to pay for programs like Medicare and Medicaid. Unknown proportions of property taxes pay for municipal employees’ health insurance. In a Medicare for All system, the cost of health care would be transparent. In a state-based universal health care system, it would be more transparent that it is now.
Commercial health insurers have little motivation to control health care costs. A) The higher the prices charged by providers, the more an insurer can discount them, which makes patients think the insurer is getting them a good deal. B) Insurers base premium charges on up to 125% of what providers bill them (medical loss ratio): the higher the provider’s prices, the larger the insurer’s overhead charges. C) Paying higher prices is a minor problem for insurers because it’s not their money: they have little “skin in the game.” The net income of the seven largest health insurers was $35.6 billion in 2019. Governments are motivated to minimize the price for good health care because they have nothing to gain by high prices and much to lose: voter dissatisfaction and less money left for other vital government services.
Commercial insurers use some profits to lobby for laws maximizing their profitability, a type of crony capitalism or rent seeking that prioritizes self-interest over health care. With fewer and less well-funded insurance companies lobbying, Congress and state legislatures are less beholden to this special interest group and can consider health care proposals purely on their merits.
Surprise medical bills from out-of-network providers affect one out of six commercially insured hospital patients. This is aggravated by private equity firms buying up provider groups in order to maximize profits from “balance billing,” and lobbying Congress to oppose any regulations. There are no surprise medical bills in universal health care systems; there is only one provider network.
The Problem The Universal Health Care System Solution
Though 60% of Americans think that government should be responsible for assuring all citizens have health care, just as they have clean water and protection by the military; neither Congress nor states (with the possible exception of Massachusetts) have succeeded in passing such legislation. Senator Sanders’ Medicare for All Act of 2019, Rep. Jayapal’s Medicare for All Act of 2019, and the Physicians’ Proposal of Physicians for a National Health Program would carry out the desire of citizens at the national level; and Maine Rep. Brooks’ Act to Support Universal Health Care, the model offered in the Maine Center for Economic Policy’s Assessing the Costs and Impacts of a State-Level Single-Payer Health Care System in Maine, and proposals in other states such as Minnesota’s Healing HealthCare plan would do so at the state level.

Compiled and edited by Daniel Bryant, MD