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Anyone listening to the discourse among presidential candidates has heard about a new proposal for healthcare delivery, Medicare for All.

No two people define Medicare for All in the same way. Is "Medicare for All" the same as "socialized medicine"? (I do not know what "socialized medicine" means.) Is the concept identical to a "single payer" system? Is it akin to the healthcare systems in Canada or Europe? Does it abolish private insurance?

This post addresses two simple questions: Would "Medicare for All" benefit patients? And would it benefit physicians? (This is a relevant question, since physicians represent a majority of the readers of this blog.)

Let's start with some basic realities.

First, our healthcare system has become "financialized" to an extreme. Every component prices its products and services to the highest level that the market will bear. Many physicians make treatment decisions based on what they are paid to do, rather than what is in the interest of patients.

Second, our healthcare system consists of payers (typically, employers or the government) and providers (typically, physicians, hospitals, pharmaceutical and device companies, and pharmacies), but these do not speak directly to each other. In most instances, the transactions among these entities are mediated by "third parties" (insurers and ). Each of these intermediaries is in the business of making a very meaningful profit in its own right, and their profits add considerably (and unnecessarily) to the total costs of healthcare in the U.S. Administrative costs are than in other countries. According to one estimate, eliminating these intermediaries over a decade.

To make matters worse, certain payers (e.g., the U.S. government) are legally forbidden to negotiate prices with certain producers (e.g., pharmaceutical companies). Consequently, per capita spending on pharmaceuticals is than in other parts of the developed world.

The result is that the U.S. healthcare system is more expensive than that of other countries, . Even among those with access to healthcare, most people with chronic illnesses are not receiving adequate care.

And according to the National Academy of Medicine, is a complete waste.

Third, millions of people have no medical coverage at all. Some are covered through safety-net programs. However, even with the implementation of the Affordable Care Act, millions still do not have healthcare, and medical bills are the most common reason for financial stress in the U.S. Two-thirds of people who file for bankruptcy to their financial woes. This is not how an advanced civilization should function.

Anyone who acknowledges these facts understands that the in the world. Far from it.

Many other countries have a single-payer healthcare system. The government is the payer, and it negotiates prices for products and services directly with the providers. However, there is no single definition of a single-payer system. The healthcare system in Canada is not the same as the one in the United Kingdom, France, or Germany. But in spite of differences, the is that the government has eliminated third-party intermediaries.

The U.S. already has such a government-run insurance system. It is called Medicare. It was established 54 years ago.

Medicare is a government-administered insurance program that currently covers hospital stays and physician visits for people ages 65 and older. According to Marcia Angell, MD, of the American healthcare system. However, Medicare does not cover most drug costs and other healthcare services. So to get coverage for most prescription drugs or dental or vision care, Medicare beneficiaries need to obtain additional coverage from private insurers.

Many people in the U.S. currently have all of their healthcare coverage through private insurance, typically provided by their employers as an employee benefit. The options for private insurance are numerous even when people are employed by the same entity. However, many private insurance plans are really minimalistic. Although healthcare is technically covered, diagnostic and treatment options are limited. Even in plans with broader coverage, insurers place meaningful roadblocks to impair access to worthwhile treatments.

Do you want to minimize disparities, advance the adoption of medical advances for all, while simultaneously eliminating the enormous costs created by profit-seeking third-party intermediaries?

You can propose that the government expand Medicare coverage to all those who now are covered by private insurance. Voila! Medicare for All.

One more thing. Any reasonable plan would expand Medicare to cover the costs of drugs. This could be achieved by allowing the government to negotiate prices with the pharmaceutical industry.

Sounds great, right?

It does not sound great if you are an insurance company or pharmacy benefit manager. With the advent of Medicare for All, the current business model of these industries would be destroyed.

It does not sound great if you are a pharmaceutical or device company. Suddenly, the government will be given incredible power to negotiate prices, and that power will undoubtedly cut into their substantial profits.

Of course, many would not be distressed in the slightest if the profits of pharmaceutical companies, insurers, pharmacy benefit managers and all others who benefit from the current financialization of healthcare were slashed.

What about hospitals? Currently, private health plans pay hospitals about 45% more than treatment costs, while government-run programs . So hospitals would see a loss of revenues, but their administrative expenditures would plunge. Without doubt, they would adapt.

What about physicians? When Medicare was first introduced in 1965, practitioners complained loudly that the program would lead to a loss of autonomy and price controls. But in 2019, most physicians have lost any meaningful sense of autonomy, and are fully accustomed to having no control over their price structures. As Michel Accad, MD, has eloquently described, most physicians now simply for the insurance industry. Their decision-making capacities are limited, and they are plagued with administrative chores. Their ability to practice high-quality medicine is severely impaired. This is causing an .

Given the opportunity to practice high-quality medicine in a low-stress environment, more than half of physicians now as the best outcome for future payment reform. Any reduction in revenues that results from a shift to Medicare-level payments would be more than offset by savings and job satisfaction benefits that would accrue from being freed of administrative burdens and costs.

What about patients? Medicare is highly popular; it is one part of the U.S. government that people think actually works the way it should. So presumably, patients would be delighted with the expansion of Medicare. Everyone will be relieved to know that an illness will not result in financial ruin. Those who are currently at the mercy of some impenetrable preauthorization process will know that a needed procedure will be covered. The management of chronic disabling and life-threatening diseases .

Conceivably -- when freed of administrative burdens -- physicians may actually spend more time listening and talking to patients.

My conclusion: Our current healthcare system is abysmal and unsustainable. We should not be debating as to whether to implement a single-payer system. Instead, we should be discussing what it should look like.

The implementation of a single-payer system involves many choices. The government could establish a healthcare budget ceiling, as exists in Canada and in the United Kingdom. That results in rationing of healthcare, with its attendant miseries. But rationing exists under the current system; it is simply hidden from public view. However, one could avoid rationing if Medicare for All were .

An interesting question is the coexistence of private insurance. Some presidential candidates would prohibit it, but in truth, private insurance coexists with single-payer systems throughout the world. In Australia, about half of the public purchases private coverage to receive a better choice of providers and faster services, and the government encourages private coverage through tax breaks.

Regardless of the facts, there is one certainty. In the coming years, we will all bear witness to an intense debate about healthcare reform. Those who stand to lose substantially in a Medicare-for-All system will invest millions in a campaign to persuade (and deceive) the public. They will claim that the program will stop innovation (which is not true) or that it will result in millions of people losing their employment-linked health benefits that they worked so hard for (neglecting the fact that these benefits will be less than Medicare as financialization intensifies).

In the end, the decision will all come down to a question of trust. Who would you choose to provide your healthcare? The U.S. government? Or the current financialized employment-based insurance system that is totally broken?

Given the exceptionally high level of public cynicism and complete lack of faith in traditional institutional structures, this will be a close call.

I believe that -- in the court of public opinion -- the voice of physicians will play the decisive role. Practitioners who feel helpless and victimized by the current state of affairs now have a unique opportunity for empowerment and the re-establishment of their profession as a mechanism for personal fulfillment and the attainment of public and individual health. They need to make an eloquent case for themselves and for their patients.

Sadly, physicians have largely acted passively to the vast changes in healthcare that have swept society during the past 30 years. If we remain passive now, we will have only ourselves to blame.

The American Medical Association (which does not represent the U.S. medical community) has said "no" to Medicare for All.

What do you say?

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