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Single-Payer Advocates Are Being Drawn Into the Wrong Debate

Warren's plan to pay for Medicare for All has sparked a conversation over how much we spend on health care, instead of how well we spend it.

Astrid Riecken/Getty Images

A premature baby costs almost a million dollars. A mental health crisis costs $30,000. A few months of dialysis costs half a million. These are the absurd charges billed to American patients for the crime of being sick, orders of magnitude out of the reach of most Americans’ bank accounts. The most unjust and insane thing about this is that the patient is expected to pay these unattainable sums for their illness out of their own pockets—and that they might be chased into ruin by the legal system which props up their pursuers. A secondary madness, however, is that these charges are so high in the first place. Healthcare is expensive, but many hospitals mark up those prices just as much as they can get away with, and no one stops them. They might not even know the extent to which they’re marking those prices up. 

These prices contribute to the United States’ vastly inflated health care spending, roughly twice what comparable nations spend. Hospital costs are just one part of this, and they have a knock-on effect of inflating other costs, like insurance premiums, which are similarly Too Damn High. Drug prices are also far higher here than in other countries. There are elevated administrative costs of paying for care with an inscrutable mix of public plans and private insurance plans—the Cleveland Clinic has said it has 210 million prices for its services because it has 3,000 different lists of prices for different insurance plans. That is just one hospital system. 

All of this makes it a happy little benefit that a single-payer system would lower overall health care spending, while shifting much of it from private payers (like patients) to the government. The efficiencies achieved by, for example, hospitals no longer having to bill a thousand different insurance plans a thousand different prices for each procedure would be just one boon; lower drug costs wrought by the government negotiating prices on behalf of all 320 million Americans would be another. But focusing too much on these particular benefits risks obscuring one of the greatest challenges faced by patients and those generally interested in the health and wellbeing of their neighbors: Getting the government to spend more on health care. 

When Elizabeth Warren released her long-awaited plan to pay for Medicare for All—which was for some reason demanded by the pundit class more loudly than it was for Bernie Sanders, who doesn’t seem to exist in the minds of our most well-compensated thought-havers despite having written the bill with which they’re all consumed—critics argued it included overly aggressive assumptions about cost-saving (though others said those assumptions might be conservative). It’s surprising that this is even up for debate: That single-payer would likely cost the country less makes sense to anyone who thinks about it for 30 seconds, due to the fact that it would contain all kinds of currently unregulated price-gouging. This is a case of the wrong question being posed. Rather than inquiring about how we will spend less on health care, we should instead ask “How can we make sure our health care spending is sensible, done in pursuit of an equitable and just system?” 

The United States currently spends almost 18 percent of its GDP on health care. Per person, we spend $10,224, which is about twice what most other OECD countries spend. A majority of this is spent by the government. The effects of pure profiteering on this cost are immeasurable. How many extra unnecessary tests get ordered each year because of the fee-for-service model? One estimate found that 600,000 patients went through unnecessary procedures, at a cost of $280 million, just in Washington state, in a single year. (Unnecessary procedures are not just costly but unpleasant for patients, and sometimes even dangerous for their health.) Medicare Advantage plans will pay for investor-owned firms to send doctors to elderly patients’ homes to perform physicals, which can uncover even minor ailments or conditions that drive up a patient’s “risk score,” thus increasing the insurer’s income from Medicare for that patient. 

The trillions of health care dollars we spend are purchasing worse healthcare outcomes than the rest of the developed world, along with a lower life expectancy, higher infant mortality, longer wait times, and more preventable deaths. Some outcomes are better on average in the United States, and others are much worse; once you stratify the outcomes by class and race, things start to look even more grim. These dollars might buy your radiologist a second yacht (or a drug company CEO a $9 million condo), but they can’t quite manage to stop black babies from dying at twice the rate of white babies. We have a system where the poor don’t get enough health care and the better-off and rich get too much.

What could this money buy us instead? Quality healthcare for all, instead of the privileged few. Quality mental health care for all, too. Regular checkups for people who go months or years without seeing a doctor because they fear the cost. More funding on drug research, instead of leaving it to drug companies to fund what they think will be profitable. Money for nurses, medical assistants, social workers, and even primary care doctors who serve low-income patients (in exchange for paying orthopedists who live in Beverly Hills less). Those staff could spend more of their time actually providing healthcare, instead of dealing with health insurance companies or trying to guide patients through the convoluted network of public programs. Most crucially, it could buy days, months, years of life for people who would otherwise die early of preventable diseases, or diseases that could be beaten back for longer. It could buy time, which those of us facing death ourselves or in our families would dearly love to have. 

Do we actually want to spend less of this money? It might be a virtue of single-payer that this system of paying for healthcare would reduce the amount of money we spend on healthcare, because we do spend more than any other country on healthcare and, as demonstrated, the way we spend it is insane. But how much less should we want to spend on healthcare? Should it be 15 percent of GDP? 10 percent? What if instead we didn’t spend all that much less, but we spent it better?

The United Kingdom spends 40 percent of what the United States spends per person, in large part thanks to the efficiencies of the National Health Service. The NHS pays less for drugs that cost Americans half their paycheck, for example, because of its negotiating power in purchasing drugs for basically everyone. But the National Health Service has been starved by both Labour and Conservative governments, and Britons are begging the government to spend more on healthcare. Appointment wait times are longer. Nurses are leaving the service in droves. A majority of people recognize that there is a funding crisis in the NHS, with 61 percent backing higher taxes to fund the NHS; another poll last year found that 84 percent “would pay more tax if the NHS’ level of service ‘improved a great deal.’” For my entire life, activists have been pushing both Labour and Conservative governments to properly fund the NHS, to provide the services everyone needs, to fairly compensate junior doctors and nurses. 

Despite what grinning conservatives might tell you, the problems with the NHS do not add up to an argument against single-payer—try telling someone whose son just died of a preventable but untreated illness that single-payer might cause unacceptable wait times—or an argument for the current system here, or the public option. They are an argument for properly funding a system that excludes nobody. If a miracle happened and single-payer was passed in 2021, the fight for health justice would not end; it would shift to pushing the government to fulfill the promise of that system, which includes spending a lot of money. 

The central purpose of medicine is to extend and improve our lives on earth. We can have longer, better lives than every generation before us because scientists and doctors have figured out how to treat illness. It’s good that single-payer would redistribute health care spending to be far more equitable, but our goal should not be to spend less on health care overall. It should be to enrich lives, and bring good health and comfort to everyone we can. What could be a better use of money than that?