Much has been made of Bernie Sanders's single-payer health care plan, released last week in a nine-page document titled "Medicare for All." The once-protest candidate is offering to deliver one of the promises responsible for transforming him into a mainstream cultural phenomenon over the past seven months. Yet as his poll numbers climb in Iowa and New Hampshire, Senator Sanders's policy prescriptions have drifted further away from reality. Even as a graduate student, with only a working understanding of health economics and the American health care system, I can tell you that Medicare for All isn't remotely sensible - neither in its details, nor in its broad-stroke goals. At its best, it is scratches on a white board at the Sanders campaign HQ in Burlington, acting as a conversation starter for policymakers in some distant future. And at its worst, Medicare for All panders to populism and exploits middle-class frustrations. It is a pie-in-the-sky promise, like building a wall straddling the US-Mexican border, or banning Muslim immigration, that speaks in a language of political tactics not so different from the rhetoric of Donald Trump.
These are bold accusations to levy against Senator Sanders, so let me explain. Critics have questioned the veracity of the plan's projected savings and tax collection figures, and have expressed skepticism over its political viability. But beyond its challenges with feasibility, Medicare for All takes a slanted approach to explaining America's failure to deliver a fair health care system to all of its citizens in recent history. Senator Sanders tells a story of winners repeatedly exploiting losers, discussing "private health insurance companies that put profits before people," and a need to "stand up to drug companies" playing God with our citizens.
It really is the case, however, that many actors have added to the chaos of our health care system, driven by profit or misinformation. Senator Sanders is correct that insurance companies have engaged in price discrimination when negotiating reimbursement rates with different hospitals, and that pharmaceutical companies have priced their products far above reasonable expectations. These forces have undoubtedly contributed towards an enormous and frankly immoral burden felt by most Americans - through fostering the "administrative waste" and the bewildering complexity of the health care system which he describes - but they are not the only culprits. Congress refuses to increase Medicare funds earmarked for residency programs, creating a bottleneck of physicians who have the skills needed to practice medicine, but lack the opportunities to undergo the training required to obtain a license. Bureaucrats burden medical professionals with ineffective job performance measures and slash their productivity. Physicians over-diagnose their patients, and exhibit financially-motivated behaviors encouraged by a market rewarding them for the number of services they order, instead of the quality of their patient outcomes. Hospitals overwork their employees and routinely face allegations of fraud. Patients often demand medically unnecessary treatments, abuse expensive narcotics, and sue the clinicians that refuse to cave in to their demands in civil court. And our society, by and large, has perpetuated an irrational fear of rationing health care - insisting that any treatment, however beneficial, is worth any cost, however expensive.
Senator Sanders ignores this cultural norm, and appears to be only interested in raging against insurance companies and pharmaceutical juggernauts, while offering shallow solutions for systemic issues featuring outside of this political narrative. He emphasizes preventive medicine, which may create a healthier population, but has been proven to have little effect on total health care costs in the long run. He offers a vague promise to increase "federal investments for training health professionals," but backs away from providing a concrete proposal outlining how our short-staffed health system will cope with the rising demand of patients seeking care. And for all of his scholarship of single-payer health systems, Senator Sanders curiously ignores the need for cost-effectiveness in his reforms. After the passage of the ACA, the United States became the only nation in the world to effectively ban cost-effectiveness research - clinical studies that factor both the therapeutic benefits of a treatment, as well as its fiscal cost, amongst a group of alternatives - from being conducted in its public institutes crafting health policies. Yet cost-effectiveness research is the hallmark of every functioning single-payer health care system, and its findings are factored into allocating medical resources and designating preferred interventions. Our laws enshrine our fear of rationing health care, and Senator Sanders still refuses to confront this harsh truth. The term "cost-effectiveness" is nowhere to be seen in his pitch for a single-payer system.
These are just a few of the ways, out of many, that Medicare for All strangely differs from the single-payer health care systems Senator Sanders has openly admired during his campaign. While most single-payer programs are funded through broad-based means, involving a mix of national sales taxes and progressive income taxes, Medicare for All is effectively bankrolled by only the very richest of Americans. While most single-payer programs embrace collaborative solutions across industries to drive down health care costs, Medicare for All promotes an "us versus them" mentality, singling out the crimes of a select few corporations. Lastly, while most single-payer programs embrace realities of rationing health care, Medicare for All only offers a fantasy, in which we continue to spend thousands of dollars on expensive treatments with little benefit, without suffering any financial consequences. However politically untenable it may be, it is morally sensible for Senator Sanders to acknowledge these trade-offs, as our society continues to pursue the noble goal of universal health coverage.
Frequently on the campaign trail, Senator Sanders has expressed a sincere belief that "health care is a right." This is a promise that warrants explanation. What services should be provided for everyone, and who is responsible for providing them? Single-payer health care systems offer one set of answers, out of many, to these questions. They are designed to distribute as many resources as possible to as many people as possible. Practically, they will involve some form of rationing health care, ideally based on a criteria of need, rather than zip code and income - as our own system has done for decades. Senator Sanders is fighting the good fight, but he owes it to his supporters to present an honest proposal advocating for his vision of our country's future.