The Blind Spot in Medicare for All

Andara Puchino

The United States is the only high-income nation to insist that health should be determined by markets and profits rather than rights and dignity. The result is that the prohibitively high cost of American health care causes tens of thousands of preventable deaths every year.

For the first time since the Covid-19 pandemic compounded this long-standing national disaster, Congress is considering the state of America’s health care system. The House recently held hearings on Medicare for All, and the Senate Committee on the Budget is convening parallel proceedings today. In this context, many members of Congress who benefit from the status quo are rehashing their opposition to Medicare for All, citing the importance of defending of “freedom” and “choice.” With thousands of people dying each week precisely because they have no choices in our current health care system, this rhetorical game should fool no one.

Although universal health care appears unlikely to be enacted by this Congress and has never even appeared on President Biden’s agenda, the current hearings serve an important purpose. They remind the US public that our existing system of for-profit health care exclusion is a deliberate policy choice, not an inevitability.

While Medicare for All would be an enormous step forward for the health of Americans and the health of US democracy, it’s essential to recognize that what determines our health care system is not simply who pays but also for what we pay. If we adopt a single-payer structure without remaking the bureaucracy by which the value of care is determined, we will perpetuate the perversity at the core of our system and its world-leading inefficiency.

Despite efforts to implement alternative models over the last two decades, a fee-for-service framework remains embedded in American health care and endures as its dominant underlying driver. Fee for service compensates doctors, clinics, and hospitals based upon number and type of visits involved in a patient’s care, creating incentives for unnecessary procedures, excessive clinic appointments, and the mountains of paperwork that have become the bane of American doctors’ daily lives. This system, which places value on specialized services rather than on primary care, is also a crucial factor behind the worsening shortage of primary-care doctors.

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