Shortly after she declared her presidential candidacy, Sen. Kamala Harris (D-CA) did something unusual for a mainstream Democrat: She made a compelling case for eliminating the private health-insurance industry as it currently exists.
“The idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require,” she explained. “Who of us has not had that situation, where you’ve got to wait for approval, and the doctor says, well, I don’t know if your insurance company is going to cover this? Let’s eliminate all of that.”
What her answer didn’t do is fully address the question, which was rich with subtext: “people out there who like their insurance, they don’t get to keep it?”
That question routinely vexes most Democratic single-payer supporters, which is why her staff quickly softened her statement to note that she and other Democrats who support Medicare for all also support back-up plans, like a Medicare buy-in or a public option. People don’t like to be told that their health plans will go away. The basic unpopularity of that proposition—people don’t get to keep what they have—is perhaps the biggest political hurdle Medicare for all supporters face, and should their objectives prove untenable it makes sense for them to have contingency plans.
But it also makes sense for Democrats to fight for their ideals in the most compelling possible way, and as close as Harris came, I think she could have gone further. Before falling back to second-best options, single-payer supporters should try to persuade people who worry about losing their current health plans that they’ll be immediately and permanently better off if they make the jump—if we all do so, together, all at once, and then never again.
Medicare for all, as proposed by Bernie Sanders, entails in its simplest form a four year transition to a single payer—the federal government—after which private health insurance as we know it will cease to exist. I am no policy expert, and believe there is room for debate over the length of the transition period, the generosity of the benefits, and what we do with all those premium dollars people will no longer be paying. But I strongly believe that in its essence Medicare for all is the only way to achieve truly universal health care.
I come at this problem from two perspectives: First, I am a doctor. As a physician I have always supported Medicare for all, mostly because I’ve always viewed accessible health care for all as a moral imperative that all doctors should fight for—particularly ones in the richest nation on the planet. The private health insurance industry is daunting and inaccessible even for people with relatively excellent plans, experience navigating the system, and an inordinate amount of time to make phone calls. True universal health care cannot grow out of this system.
I spend approximately 10 percent of my clinical time filling out forms or making phone calls to insurance companies to justify tests or medications. This number would be much higher if I did not work in a clinic with an outstanding and large support staff, which not all physicians have access to. And yet, as nearly all doctors can attest, virtually none of this time is spent on patients who have Medicare—the best and most reliable payer in nearly all practices. Perversely, I make up some of the time I waste on administrative tasks when patients have to cancel their visits with me because they’ve changed employers or lost jobs. My clinic is no longer in their network or they simply are “between insurance plans.” Not once have I lost a patient because he or she turned 65 and enrolled in Medicare. In fact, multiple patients have shared with me what a relief it has been to become Medicare eligible.
Insurance companies carefully maintain this impenetrable layer of bullshit in the interest of saving money. It delays care for patients resulting in disease progression, complications and unnecessary suffering. Ironically, in many cases, if the patient is fortunate enough to get care eventually, it is more costly because of the delays. These delays also lead to frustration and burnout among physicians, patients, and caregivers. The burnout is palpable in large clinical practices and it places an incalculable burden on an already cracking system.
I am also a patient. I have had a chronic disease since the age of six. Over the last few years my symptoms necessitated a costly immunosuppressant medication. This medication changed my life. I’m profoundly lucky to have had access to excellent and affordable medical care through my employer, and that my insurance covered all but $40 per month of my medications. I considered myself unfairly liberated from the insurance-related hassles many of my patients—who don’t work in hospitals and have worse insurance—face.
Until last year.
In July, 2018, I got a promotion. I did not switch employers or even departments, but because my title changed, I had to switch insurance providers. Again, I was lucky and I switched to another excellent health plan. I told my providers about my new plan and received my care, testing, and medication uninterrupted. Then, in January 2019 I received a bill for $17,000. It seems that both of my pharmacies continued to bill my old insurance company for my medications from July 2018 through September 2018. My old insurance company paid these bills, but when they realized their error—my plan with them had ended on June 30, 2018—they promptly came after me for the money.
After a moment of panic I realized that I actually had uninterrupted insurance coverage through this time, and believed that all I’d have to do is file a claim with my current insurance company in order to reimburse my old insurance company. They’d already approved the medication and had been paying for it for several months. I made a couple of calls to the bill collectors who helped me find the appropriate claim forms and told me the process from there should be smooth.
It has not been smooth.
First, the information the claim forms request is absurd and transparently intended to discourage people from filling them out. This part of the process required four calls to two pharmacies, hours wasted on hold, multiple emails to providers, and two weeks of waiting on the appropriate paperwork, so that I could fill out the form. Once I’d gathered all the paperwork, I sent my packet via certified mail. It was logged as received five days after I sent it, and I followed up by phone about a week later. The company claimed no one had received it. After spending 30 or 40 minutes on the phone, the representative gave me a fax number and asked me to re-send my packet. I don’t really know how to fax things because this is 2019, but 24 hours later I got confirmation that the fax had sent. A week later I called to inquire about the status of my claim, but couldn’t find a single person who was able to help me. At one point, I asked for a phone number or email directly to the claims department and was told, “unfortunately the claims department does not have a phone number that you can call.” That is verbatim. Two months after receiving the initial bill, the bulk of my claim has been denied. I am entering an appeals process and anticipate this will take months longer to resolve.
And it all happened because I got a promotion at work.
It happened despite the fact that, in health-care terms, I am among the most privileged people in the country. It happened despite my excellent private health-insurance plans. Many of my patients are not so fortunate and some have diseases that are far more relentless than mine.
All of this is relevant to the more abstract political debate over Medicare for all, because it exposes both the hollowness of the attacks on the idea, and how easily answered the public’s legitimate concerns about their current plans are.
My health insurance will change again this summer when I move to a new job in a new city and I’m terrified that my health will backslide or I will receive another exorbitant bill after the transition. If rather than transitioning to a different private plan in July 2018 I had transitioned to Medicare I would be in a much better position today, and if I could transition into Medicare later this year, I would know, for certain, that I’d never have to go through any of this again.
That includes the part about switching plans.
Even if Congress never touches the health care issue again, almost everyone who is satisfied with their current health-insurance plans will lose them at some point. They will change employers, get promotions, lose jobs, or they will do nothing at all and their carriers will simply stop offering the plans they like. Inevitably, thousands if not millions of those people will find themselves in bureaucratic nightmares like the one I’m dealing with when their new insurers try to exploit the churn in the market for profit.
On top of everything else Kamala Harris described in her pitch for single payer, Democrats should home in on this. Will you have to switch plans? Yes. But you will have to switch plans at some point anyhow, and when you do, you will be at the mercy of a system that will try to milk your changing circumstances, for profit, at your expense. Let’s deny them that power. Let’s switch, together, all at once, and then never again.
It will of course be an administrative challenge to transition the population to Medicare by a certain date. But the worst thing Democrats could do is try to outsource that challenge to millions of us who have better things to do in life than argue with insurance companies and collections agencies, and who don’t have $17,000 lying around to make the problem go away. We should debate the best way to accomplish the transition and take great care that good, competent people are put in charge of it. But then we would be done. No one would have to turn down an exciting job opportunity because they’d lose their current insurance ever again. No one would have to switch their doctors because their employers found a cheaper contract with a different insurance company. And no one [cough] would get billed for expensive tests and medications ordered around the time they switched between private plans.
I believe in this vision for health care in America as both a doctor and a patient. I believe that when we finally make the transition we will realize, collectively, almost right away, that our old, private, employer-based insurance system was barbaric, and we’ll marvel that we suffered under it for so long. And I think if we settle for Medicare buy-in, or another half measure, then truly universal health care will remain elusive until a future crop of leaders restarts the debate all over again, and gets it right. But we won’t ever make the leap if the country’s most powerful liberals refuse to make the full, honest argument to the public, and let the chips fall where they may.
Lisa Beutler is a physician-scientist in San Francisco. She tweets @lbeutler7. The opinions expressed here are her own and do not necessarily reflect those of her employer.