Bernie Sanders has finally outlined how he'd pay for his nearly $14 trillion Medicare-for-all plan, but lots of unanswered questions remain.
Shifting the U.S. to a single-payer system would be very disruptive, experts say. The eight-page proposal Sanders released Sunday night does not explain how Americans would transition from our current health care model, which relies heavily on private insurers, to a government-run program more akin to those found in Canada and Europe. It also lacks details on how his universal health care plan would actually work.
"We've never had a serious debate about single payer in this country. We haven't had to work out all the details," said Larry Levitt, senior vice president at the Kaiser Family Foundation.
Here's what we know about Sanders' plan:
Under Medicare-for-all, Americans would have comprehensive care, covering doctors' visits, hospital stays, long-term and hospice care, vision, dental, mental health and prescription drugs. They would no longer have to pay private insurance premiums, deductibles or co-pays.
To pay for it, Sanders is calling for a new 2.2% income tax on all Americans and a 6.2% levy on employers. But he would also hike taxes on the wealthy. Sanders' campaign, however, argues that average Americans would save more than $5,000 by scrapping their monthly premiums.
Here's what we don't know:
Would doctors and hospitals be willing to take big rate cuts?
Sanders' plan relies on $6.3 trillion (over 10 years) in savings, much of it coming from lowering the rates paid to doctors, hospitals, home health care providers and drug manufacturers.
Doctors would be paid 10.7% less and hospitals 9.4% less than what they receive from Medicare now, according to an analysis done for the Sanders campaign by Gerald Friedman, a University of Massachusetts at Amherst economics professor. He argues that providers will be able to handle the cuts because they'll be able to save money on billing and insurance-related work.
Friedman pointed to a 2011 study in industry journal, Health Affairs, that estimated the average physician in Ontario spent about $22,200 per year interacting with Canada's single-payer agency, while American doctors spend close to $83,000 a year, on average, dealing with insurers.
Reimbursement rates have long been a very sensitive topic for medical providers. Private insurers have been pushing doctors and hospitals to accept lower rates, prompting some to drop out of insurers' networks. Some hospitals, especially in rural areas, are struggling to remain open. And Medicare already pays providers less than insurers.
The American Hospital Association declined to comment, citing the looming snowstorm. The American Medical Association did not return calls seeking comment.
Will there be a separate private health care system?
While there's no single blueprint for universal healthcare, doctors are typically either in the single payer system or they're not.
Medical providers who opt not to join the government program could set up a private practice. It may be similar to doctors who don't accept any insurance. They set a rate and patients can decide whether to pay out-of-pocket.
How can you keep spending down when 29 million people are expected to gain insurance?
That's a good question. Sanders' plan relies on a slowdown in the growth of health care spending, but that will be harder to achieve with millions of new enrollees flooding the system.
Health care spending rose by 5.3% in 2014, in large part because of the nearly 9 million people who gained coverage under Obamacare that year. Prior to that, the growth rate had been at historic lows of 4% or less for several years, in large part because of the weak economy.
If there are no private insurers and no co-pays, does that mean I can get any treatment I want and all claims will be paid in full?
One reason why insurers in the U.S. have been increasing deductibles and co-pays is to curb consumers' health care spending. Under single payer, there would be no insurers to approve or deny claims. But in practice, costs would likely skyrocket if there were no controls.
Single payer advocates say that doctors would be in charge of limiting unnecessary visits, tests and procedures. Also, since all billing would go through a sole payer, the government could flag any provider submitting abnormally high claims, said James G. Kahn, a health policy professor at the University of California, San Francisco.
Other countries, however, have instituted different ways of reining in spending. For instance, in England, a national institute conducts cost-benefit analysis for various treatments and decides what doctors working for the National Health Service can provide.
Elsewhere, costs are kept down in other ways. Canadians, for example, may have to wait weeks or months for some medical services, such as seeing specialists. A 2014 Commonwealth Fund report that looked at 11 developed countries found that Canadians were least likely to be able to get a same day or next day appointment when sick and were most likely to have to wait at least two months to see a specialist.
Every health care system has to have ways of deciding whether care is necessary and reasonable, said Harold Pollack, an urban public health researcher at the University of Chicago. But Americans are very adverse to the idea of rationing care. Obamacare bans the government from conducting cost-benefit reviews, he said.
What happens to all the people who work in insurance and medical billing?
Some 2 million people who work in insurance and medical billing could be displaced under a single payer system, Friedman said. But many could be shifted to other health care jobs, he argues. Instead of
Physicians for a National Health Program, which advocates for a single payer system, estimates it would cost $20 billion to retrain and place displaced workers.
A universal health care bill introduced in 2013 by Michigan Representative John Conyers, a Democrat, would provide displaced employees with retraining and temporary transition payments equal to their annual salary, not exceeding $100,000 a year. A single payer bill introduced that year by Sanders did not contain such programs.