An obvious argument for Medicare for All goes like this:
Americans die about three years sooner on average than their Canadian or British counterparts. The most obvious explanation of this difference is that Canada has already implemented “Medicare for All” and Britain has gone even further in the same direction, not just paying for its citizens’ hospital bills but nationalizing the hospitals themselves. We want Americans to live longer too. So we should adopt a similar system!
I don’t know about you, but I find that argument pretty persuasive. And a lot of conservative and libertarian counterarguments are downright silly. For example, Kentucky Senator Rand Paul once claimed that anyone asserting that they have a “right” to healthcare guaranteed by the government is thereby saying that doctors should have to treat them. This, Senator Paul said, means that doctors and other medical professionals would be slaves. The obvious and decisive objection is that the United States already guarantees universal rights to services ranging from K-12 education to fire protection to legal defense and has somehow managed to do this without enslaving school teachers, firefighters, or public defenders.
That said, there are several arguments against Medicare for All that might sound more plausible than the Enslaved Physicians Argument. Here are a few that I see a lot:
- The life expectancy differences between the U.S. and countries with socialized systems are the result of less healthy lifestyles in the U.S.
- Medical innovation will suffer without market incentives.
- Socialization means that healthcare will be rationed by a cold and heartless bureaucracy.
- Most people like their private health insurance. Forcing everyone onto Medicare for All violates freedom of choice.
- The Veterans Health Administration is a mess—why would Medicare for All be any better?
- Obamacare shows that the government getting involved in healthcare makes it worse. Whatever genuine problems we have in the U.S. are a result of our not having a truly free market in healthcare. The answer is less government, not more.
- Doctors won’t work for Medicare rates. If we adopted Medicare for All, we’d end up with doctor shortages and long wait times like they have in Canada and the U.K.
This Prager U video, for example, hits #2, #3, and #4. Texan Congressman Dan Crenshaw covers most of the same ground here, as well as touching on #6. All seven arguments are made in rapid succession by the host and the two right-wing guests as they talk over the token defender of Medicare for All in this Fox Business panel.
Let’s take them one at a time.
1. The life expectancy differences between the U.S. and countries with socialized systems are the result of less healthy lifestyles in the U.S.
What this argument fundamentally ignores is the extent to which healthcare impacts lifestyle. So, for example, perhaps an individual would exercise more regularly if their untreated asthma weren’t so severe and they hadn’t rolled their ankle years earlier. (It still hasn’t fully healed, but they can’t afford to see a doctor about it). Perhaps they are more likely to purchase organic vegetables from the farmer’s market instead of the cheap, sugary, fatty, and salty foods from Walmart if they weren’t spending so much on prescription drugs, doctor visits, and monthly health insurance payments. You may roll your eyes at this claim and insist that fruits and vegetables aren’t that expensive, and that people are not going to stop eating donuts and start jogging just because our country gets Medicare for All. There may be some truth in that assessment, but it’s also the case that poor health makes it more difficult to lead a healthy lifestyle. Medicare for All will provide all Americans with the preventative care they need, dealing with health issues before they snowball into something much worse.
Are beer-and-hockey-loving Canadians really that much more health conscious than Americans? I’m not so sure. As unlikely as it seems to me, though, the differences between overall life expectancy in the U.S. and Canada could be all about lifestyle. But what about infant mortality? The number of infant deaths per 1,000 live births in the United States is 5.8. It’s 4.5 in Canada. The British number is 4.3. American babies are a lot less likely than their parents to be obese, and it seems to me that the overall lifestyle of American babies, Canadian babies, and British babies is largely similar. They all pretty much just lie there.
Of course, even if American babies are a lot less likely to be obese than their parents, there are various ways in which the unhealthy lifestyles of parents can cause health problems in their infant children. Gestational exposure to alcohol, for example, can lead to an increased risk of infant mortality. On the other hand, Americans actually drink less on average than citizens of any other country in the developed world. (And while smoking rates are similar in the U.S. and Canada, Brits both smoke a lot more than we do and have the lowest infant mortality rate of the three countries.) But perhaps there’s some parental lifestyle factor that could at least partially account for the infant mortality gap.
Whatever’s true about that, the really damning statistic is that the overall rate of “mortality amenable to healthcare”—statistician-speak for “people who died even though they could have been saved by timely medical intervention”—is 78 per 100,000 in Canada, 85 in the U.K., and a whopping 112 in the United States. Spend some time with the numbers. You’re not going to find a country with (i) a similar level of economic development to the United States, (ii) a universal health insurance system, and (iii) a higher rate of mortality amenable to healthcare.
2. Medical innovation will suffer without market incentives.
The picture critics paint on this point sounds intuitive enough on first glance. Pharmaceutical companies make more money selling drugs in the United States than they do in countries whose government-run systems set lower rates of reimbursement. If they started making less money in America, they’d have less of an incentive to innovate. Hence, innovation would suffer.
Dig a little deeper, though, and we can ask at least two follow-up questions. First, is it true that our current system is good for medical innovation? Second, even if it were, would this be enough to make that system morally acceptable?
We’ve already established that Medicare for All and similar systems do a better job of preventing medically preventable deaths in the here and now than America’s system of mostly private health insurance. Let’s assume for the sake of argument that (a) keeping the insurance industry mostly private will considerably speed up the rate of medical innovation (when compared to the pace of medical innovation in a world where America adopted Medicare for All), and that (b) this sped-up pace of innovation will, over the long term, more than make up for the deaths that will result from keeping our insurance system in mostly private hands. Unless we’re willing to make hardcore utilitarian assumptions about morality, it doesn’t follow from (a) and (b) that maintaining our current insurance system is morally defensible. For one thing, socialized healthcare improves health outcomes now and it’s at best speculative that innovation will maybe, down the line, save more lives. Innovation is to a significant extent a matter of luck. Does it really make sense to hold off on providing everyone with the medical care they deserve because it might harm innovation, which might sometime in the future save more lives?
Even if we could be sure that this gamble would work, it doesn’t follow that it would be morally defensible. Think about one of the statistics references above—the much higher rate of infant mortality in the U.S. as compared to Canada and the U.K. If you’re an uninsured or underinsured American parent, anyone making the Medical Innovation Argument is essentially saying, “Sure, if we gave you national health insurance, your baby would have a greater chance of surviving right now, but by letting your baby die—by in effect sacrificing it to the hungry gods of the free market—we’re creating financial incentives that will lead to the development of new treatments that will save other babies in the future. So you really have no legitimate complaint!”
Medicare for All advocates believe that people (of all ages) have a right to healthcare. If you accept that premise, the Medical Innovation Argument isn’t persuasive, even if it were true that American-style market healthcare is good for medical innovation. As a matter of fact, the opposite is true.
In their excellent book People’s Republic of Walmart, Leigh Phillips and Michal Rozworski point out that more than three-quarters of really new drugs—NMEs for New Molecular Entities—are already developed in government labs. The most profitable (and hence most common) procedure is for drug companies to give slight tweaks to already-existing drugs that they can then patent. And when it comes to one of the most important kinds of medical research—the development of new antibiotics—the picture painted by Phillips and Rozworski is extremely disturbing.
Amid a growing global crisis of anti-microbial resistance, in which microbial evolution is defeating antibiotic after antibiotic and patients are routinely dying from routine infections, pharmaceutical companies have all but given up research into new families of the life-saving drugs, simply because they are not profitable enough. That amputation or surgery to scrape out infected areas might return as common medical responses is not a pleasant thought. But this alternative was the only one left to the doctors of 19-year-old Antonio Ricci of Seattle when they surgically removed part of his leg, following repeated infections from drug-resistant bacteria—acquired in a train accident in India—that could not be treated, even with highly toxic last-resort antibiotics. Each time the infection returned, more and more of the leg had to be cut off. Although Ricci has since recovered, he has lived in perpetual fear of the reappearance of bugs that cannot be fought. As a 2008 “call to arms” from the Infectious Diseases Society of America (IDSA) put it, “[Antibiotics] are less desirable than other drugs to drug companies and venture capitalists because they are more effective than other drugs.”
That last point may sound counterintuitive. Wouldn’t principles of supply and demand dictate that the most effective drugs were the most profitable to manufacture? As it turns out, they wouldn’t. No matter how much they gouge patients and their insurance companies for a few weeks’ supply of antibiotics that will, if effective, never need to be used again, the drug companies will make less money off these sales than they will off drugs that patients have to continue to use over long periods of time.
If you’re concerned about the state of medical research, the best option isn’t to preserve a free market in health insurance. It’s to go a step beyond single payer insurance and nationalize the pharmaceutical industry so future research can be directed toward our most urgent needs. We do not have an argument against Medicare For All here. What we have is in fact an argument that we need colossal new public investment in the development of new treatments. We shouldn’t accept the false tradeoff between innovation and the right to health care: the only morally acceptable system is one that can do both.
3. Socialization means that healthcare will be rationed by a cold and heartless bureaucracy.
There’s an important equivocation here. If “rationing” just means that the resources of a system aren’t unlimited, so not every patient is guaranteed to get every treatment that might possibly help them, then every health system involves rationing. Under the current American system if your insurance provider won’t cover something and you can’t afford to pay for it out of pocket, you don’t get it. (Opponents of socialized healthcare don’t seem to care about this type of rationing. With socialized healthcare, everyone receives a minimum standard of care, whereas now, only those who can afford it do.) But if “rationing” means what it sounds like it means—if, in other words, it carries a connotation of miserly “rationing out” of extremely scarce resources—then well-funded national health insurance systems needn’t involve “rationing.”
To see the difference between the two senses of “rationing,” think about military spending. The American military has a finite amount of weapons and ammunition. It wouldn’t be possible for it to simultaneously make war on every other country in the world at the same time. But no one would normally describe America’s lavishly well-funded military as having to “ration out” guns and bullets.
If we stick to the first sense of “rationing,” we can see how strange the “rationing” complaint is by thinking about other kinds of potentially life-saving services. Fire departments don’t have unlimited resources either. If too many fires start at the same time, they might not be able to put them all out. Now, imagine that we had a system in which most people weren’t eligible for government-sponsored fire protection. When there weren’t enough fire trucks to put out all the fires in a given city, the people who can afford to pay top dollar for really good fire insurance plans would have the best chance of having a truck come put out the fire at their houses. We can argue about whether this is accurately described as a form of “rationing,” but I hope we can all agree that it’s just about the least fair and least reasonable possible way of determining where to send a limited number of fire trucks.
Some people might be tempted to say that the issue isn’t rationing per se but rationing by bureaucrats. The idea here is that even if there’s some sense in which any system for allocating scarce resources is “rationing,” letting the chips fall where they may in a free market isn’t as bad as empowering individual gate-keepers to make these decisions.
The reasonable core of this concern is that everyone rightly resents having imperious bureaucrats second-guess the decisions of doctors and patients. But here’s the thing: If you have private insurance, abstract “market forces” aren’t denying your claim. That’s being done by individual gate-keepers who work for your insurance company. “Yes,” a critic might reply, “but I can change my private insurance company if I dislike my individual gate-keepers, whereas with the government I’m stuck.” But the wonderful thing about living in a democracy—which our fictitious critic forgets—is that we can choose our individual gate-keepers. If you’re unhappy with the way the healthcare system is being run, you have the right to vote out the people who are overseeing it. And, in fact, a Medicare for All system affords more people more choice, because there are millions of people right now without healthcare who are denied the choice entirely.
You can say that the power of these private bureaucrats is more limited than that of public bureaucrats because even after they deny coverage you can pay for the treatment out of pocket. But if you don’t have the money in your pockets, that “right” is very unhelpful. It’s as if you live on an island and the authorities have closed down the only bridge going to the mainland, but the police officer who turns you away from the bridge helpfully reminds you that if you can afford a private plane, you have a right to buy one and use that to leave the island.
If your goal is to minimize the number of bureaucrats in the system, then you should support Medicare for All. The insurance companies have market incentives to deny coverage wherever this is possible. While socialized systems sometimes have to make hard decisions when they hit the limits of their resources, coverage rules tend to be far simpler, more standardized, and more transparent. Fewer bureaucrats are required.
In fact, another common argument against Medicare for All is that most “administrators” at insurance companies would become redundant. (When we’re supposed to sympathize with such people, they’re “administrators.” When we’re supposed to hate them, they’re “bureaucrats.”) In any case, as Matt Bruenig explains here, they’ll be fine under Medicare for All. Meanwhile, the rest of us will be far less likely to ever have to talk about our healthcare with anyone who isn’t a doctor or a nurse.
4. Most people like their private health insurance. Forcing everyone onto Medicare for All violates freedom of choice.
Like most Medicare for All advocates, I have trouble taking the premise that anyone anywhere “likes” their health insurance company seriously. Liking your doctor is one thing—and, by the way, one of the glories of Medicare for All is that you’ll never be told that the doctor you used to go to is “out of plan” ever again. (The only way to go “out of plan” with national health insurance is to leave the nation.) But are there really human beings who are personally emotionally attached to the rent-seeking financial entity that gets between them and their doctor?
Medicare for All critics insist that the answer is “yes.” In fact, they say, there is statistical evidence for this. Lots of surveys show that a majority of people with private health insurance are “satisfied” with their current insurance. Therefore most people wouldn’t want you to replace that insurance with Medicare for All.
One problem with interpreting “satisfied” as “wants to continue to be privately insured rather than publicly insured” is that there are also plenty of surveys showing majority support for Medicare for All. Not all polling shows this, of course, and a lot depends on how the question is asked. (If lots of people weren’t unsure about how they felt about Medicare for All, I wouldn’t have bothered to write this article!) No matter how you slice these results, though, the numbers only add up if there aren’t lots of people who are both open to nationalizing health insurance and “satisfied” with their private plans.
That’s a pretty compelling reason to think what should be obvious on reflection in any case—that most survey respondents take “I’m satisfied with what I have” to mean “I don’t want to switch to a different private insurance company or lose the amount of coverage I currently have.” That’s what’s important: What people really care about is not losing coverage, not “keeping a particular corporation in charge of their healthcare.” Survey questions that imply Medicare for All means “losing your insurance” are actually misleading and tell us little. “Losing” implies that people will have less insurance after the transition to Medicare for All, which is what they’re worried about. Medicare for All is not “taking away” people’s insurance, in the sense that they will have less coverage; it’s changing the payment structure of their insurance, routing money through a public entity rather than a private one.
Even so, you may argue, Medicare for All could violate freedom of choice even if a majority of the public doesn’t want to keep their private insurance. Standard Medicare for All proposals would give Medicare a monopoly on at least basic health insurance. This is how Canadian Medicare works. While many Canadians have supplemental private insurance, it’s illegal to charge insurance customers for “duplicate” coverage of what’s already covered by the public plan. As I’ve argued elsewhere, such a public monopoly on at least basic insurance is a positive good both in terms of cost control and avoiding an unjust two-tier system. But doesn’t it violate freedom of choice?
In a limited sense, perhaps, in that people do not have a particular choice that they used to have. Any time you make it illegal to sell something, you’ve limited consumers’ choices in so far as they no longer have the option of buying that kind of thing. All sorts of health and safety regulations (quite legitimately) limit our choices in this way. So would Medicare for All. It doesn’t follow, however, that instituting Medicare for All would represent a net reduction rather than net increase in most people’s personal autonomy and freedom of choice. Think about people who don’t quit jobs they hate because they don’t want to lose their employer-based insurance. Or for that matter spouses who don’t leave bad or even abusive marriages because they don’t want to lose the insurance they have through their spouses. Those situations strike me as more important restrictions on people’s ability-in-practice to live their lives in whatever way they choose than taking away their ability to choose between Aetna and Blue Cross Blue Shield—especially when we pause to consider that, for most of us, those decisions are actually made by our employers.
“But don’t employees choose their employers?” Sort of, but sometimes your insurance plans change after you’ve been hired or you desperately need a job and will settle for one with inadequate health insurance. If you’re actually committed to meaningfully expanding freedom in American society, then it’s crucial that you support decoupling healthcare from employment so that every person in the country gets the care they need, independent of their employment, marriage, and any other irrelevant factor. It’s hard to say that something violates “freedom of choice” when it ends up giving you more choice over your life: more choice of doctors, more choice of employers, and more choice over how to use the money you save in healthcare costs.
5. The Veteran’s Health Administration is a mess—why would Medicare for All be any better?
There’s considerable dispute about the degree to which the V.A. is or is not a mess. The Medicare for All critics who note that Americans with private plans tell pollsters that they’re “satisfied” with their insurance never seem to want to talk about the fact that Medicare and Medicaid recipients are even more likely to report being “satisfied.” Moreover, the groups that are the most likely to report being “satisfied” are… veterans and active-duty servicemen, who get their healthcare at government-run hospitals.
There are certainly well-known V.A. horror stories. Defenders of the program argue that unrepresentative cases are hyped up by those who want to use them as a pretext for privatization. I’m sure there’s some truth to that, but that doesn’t mean that the stories themselves aren’t real. The V.A. is often severely underfunded by the same politicians who vote for never-ending wars in the first place.
Let’s assume the worst. Here’s an obvious follow-up question: Britain’s NHS is basically “the V.A. for All,” yet far from being a “mess.” It delivers far better health outcomes than America’s mostly private system. It’s nationally beloved, for obvious reasons. In fact, it’s so popular that even British Conservatives have to at least pretend to support maintaining the NHS. If they didn’t, they’d never win another election.
This isn’t a matter of British people perversely loving a bad healthcare system due to some mysterious cultural differences between Britain and the United States. Citizens of the U.K. may have odd habits like drinking lukewarm beer, but I’m fairly certain that what they want from doctors when they get sick is pretty similar to what Americans want under the same circumstances. And remember—Brits live longer and have lower infant mortality and lower “mortality amenable to healthcare” than Americans. Their “V.A. for All” system works well. So what’s the difference?
Less than one-half of one percent of all Americans are military veterans. You can underfund the V.A. without most people noticing. You can build a far more powerful political coalition to defend the funding levels of a universal system like Britain’s NHS or the Medicare for All system democratic socialists want to institute in this country. The problems with the V.A. are not inherent to government run healthcare: The success of government-run systems around the world shows that problems are a result of how you run a system rather than whether or not it is public or private. In fact, all the V.A. shows is that we need to make our demands more comprehensive: not just a public system, but a better public system.
6. Obamacare shows that the government getting involved in healthcare makes it worse. Whatever genuine problems we have in the U.S. are a result of our not having a truly free market in healthcare. The answer is less government, not more.
The first problem with this argument is that, in at least some important ways, Obamacare has actually made the healthcare system better. (Medicaid expansion has saved lives. So has the ban on discriminating against people with pre-existing conditions.) Obamacare critics are right that healthcare has become less affordable for most people every year, which certainly undermines the central promise written into the name of the law, but that was happening every year before Obamacare was passed. The argument about whether costs are rising more or less slowly than they would have otherwise, though, is a lot more complicated. A more modest and defensible claim would be that Obamacare hasn’t fixed most of the problems with America’s market-based healthcare system.
That much is certainly true, but it gives us no reason whatsoever to think that a totally different type of government intervention wouldn’t be able to do that. Just as it doesn’t follow from “Chihuahuas are dogs” and “Greyhounds are dogs” that Chihuahuas would be just as good at racing as Greyhounds, it doesn’t follow from the premises that “Obamacare is a government program” and “Medicare for All would be a government program” that Medicare for All would be just as ineffective in solving the problems of our healthcare system as Obamacare.
You know what’s even more like Medicare for All than Obamacare? Canada’s universal Medicare program! There are differences, to be sure. The Medicare for All bill proposed by Bernie Sanders would cover dental care, for example, which isn’t currently covered by the Canadian system. (Canada’s social democratic party, the NDP, has been campaigning on a platform of extending Medicare to cover this and a few other gaps.) Even so, in evaluating how Medicare for All would be likely to work, it’s bizarre to focus more closely on the failures of a very different government program than on the successes of a vastly more similar program.
You can argue that some hypothetical free market solution would work better than either Canada’s government-run system or our (for the sake of argument) insufficiently free market healthcare system. But if you want to convince anyone, it would be nice if you could point to some real world examples. The fact is, though, that there just aren’t any. (Libertarians sometimes bring up Singapore. They shouldn’t. While the Singaporean system is closer to a hard-core version of Obamacare than it is to the single payer model I favor, it’s still further from an unregulated health insurance market than what we have!)
Imagine that I used this argument to explain away all the issues that led to the collapse of the USSR: Sure, the Soviet economy had a lot of problems. But that’s because it wasn’t really Full Communism. They still used money, for example. I’m confident that if they’d gone even further in the direction of a completely planned economy—further, in fact, than any real country in history has ever gone—it would have worked extremely well.
The way that sounds to you, conservative reader, is pretty much the way “a truly free market in healthcare would solve everything” sounds to the rest of us.
7. Doctors won’t work for Medicare rates. If we adopted Medicare for All, we’d end up with doctor shortages and long wait-times like they have in Canada and the U.K.
While the point is often exaggerated, it is true that wait times are somewhat longer in Canada and the U.K. than they are in this country. In the age of three-second Google searches, however, no one has any excuse for believing that this is because socialized health systems suffer from “doctor shortages.” Canada and the U.S. have exactly the same rate of physicians per capita (2.6). The British rate is a bit higher (2.8). And the highest rate in the world (8.2!) can be found in Cuba.
The reason wait times are higher in countries with socialized health systems isn’t that there aren’t as many doctors. It’s that there are more patients.
Of course, those waiting times could still be reduced by increasing the supply of doctors. If you want to do that, you should support two other left-wing policies typically endorsed by Medicare for All advocates—Free College for All so people can become doctors without burying themselves in student debt, and a more lenient immigration system so it would be easier for foreign doctors to move to the United States.
Let’s assume for the sake of argument that for whatever reason we couldn’t combine Medicare for All with these other policies. We can implement it a la carte or not at all. How much weight should we assign to the Argument from Longer Waiting Times?
If the issue were that Canadians were dying in droves while they waited for specialist appointments, that would be a serious objection to Medicare for All, but we’ve already established that Canada has a much lower rate of “mortality amenable to healthcare” than the United States. Anyone who knows this but still objects to Medicare for All on the basis of wait times is in essence expressing the concern that the lines will be longer than the ones they’re used to because more people will be allowed to stand in them. Worse yet, from their perspective, everyone will be standing in the same line. (If America gets Medicare for All, upper-income Canadians can’t even go to the U.S. to buy their way to the head of the line!) A different way of putting all of this would be that basic fairness will have been achieved. Let’s do that.
Opponents of Medicare For All throw whatever talking points they can think of at it. The more Americans hear about single-payer healthcare, the more the insurance industry will viciously fight back with half-baked arguments designed to scare people into thinking that Medicare for All will mean worse, more expensive coverage rather than better, cheaper coverage. We have to be prepared. We need to understand the arguments against Medicare for All and be able to show why they don’t hold up. The case for the policy is straightforward and powerful, but people are also easily frightened by industry talking points. They need not be, though. Medicare for All is a good idea that will improve our lives and make us healthier and happier.
Correction: this article originally stated that Americans live five years less than Canadians and Brits, rather than three.
