How Medicare for All would affect the doctor-patient relationship

The Democratic candidates need to face the issue that single-payer health care will fundamentally impact the doctor-patient relationship.

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In the lead-up to Tuesday night’s Democratic presidential debate, much of the back and forth on health care in the Democratic primary boils down to one theme: How can the country provide low-cost, high-quality health care to all Americans as quickly as possible? Of the four leading candidates — former vice president Joe Biden, former South Bend, Ind., mayor Pete Buttigieg, Senator Bernie Sanders of Vermont, and Senator Elizabeth Warren of Massachusetts — there is little distance between them on the desired outcome: universal health care and quickly.

This isn’t a revolutionary idea. At its core, the Democratic Party has been committed to this elusive ideal for over 80 years, dating back to FDR. Which is why, if they are united on broad health care objectives, why all the manufactured angst?

Biden’s public option proposal and Buttigieg’s Medicare for All Who Want It plan are essentially the same as Warren’s revised three-year phased transition to Medicare for All, without the arbitrarily narrow time limit. And if three years is nonnegotiable to Warren, then the balance of power in the Senate by 2022 matters enormously for passage of her plan. It is far from a sure thing that Democrats will win (and then retain) control of the US Senate with a President Warren in the executive office.

Instead of pinning major Sandersonian reform to political uncertainties, then, it’s more important to consider that patients and the health systems that care for them need time to adapt to changing payer models. Even if pundits and economists overlook this reality while extolling the financial breakdown of Medicare for All, major health reform will fundamentally impact the doctor-patient relationship.

This is likely to happen in many ways that Sanders or Warren will be loathe to discuss on the campaign trail. In countries like England or Australia, for example, long wait times for routine and subspecialty care have created clear market incentives for a private health insurance industry to take root. The idea is simple: If you want quicker service, you can buy your way to the front of the line. It turns out that many people want care on their own terms, just like many of us Americans. Why don’t we wrestle with this crucial reality instead of ignoring it and saying it will all just work out?

It is hard to imagine the degree of potential upheaval and disruption to health care access that would accompany an overnight (Sanders) or even 3-year transition (Warren) to single-payer here. Providers would be expected to see more patients at decreased reimbursements rates and hospitals would be expected to find capacity to house all this care, also at decreased margins. Unless hundreds of thousands of dollars in student debt relief were to accompany any Medicare for All bill, providers will be strained bill, providers will be strained (medical school costs a fraction of the price in England, Australia, and Canada, for example). Building a single-payer health system by further overworking and over-leveraging the already overworked and overleveraged is foolhardy. This is to say nothing of the separate realities that would face hospitals in America under a Warren/Sanders health care plan. Especially now with rural hospital closures at a 10-year high, single-payer reimbursements will worsen margins for community and rural hospitals and may force additional closures.

That’s why ushering in change more slowly is important, even if it’s a less sexy sell on social media. If gradually phased in, people will have the opportunity to evaluate the care they receive through a government-funded program (relative to, say, their employer health benefits), and they’ll make a permanent swap on their own terms. Over time, Medicare will grow at the expense of the private health care industry, making the latter obsolete. Alternatively, we could follow the path of Australia, where universal health care is guaranteed to all and those who can afford additional supplementary health insurance may do so.

Moving forward, the Biden-Buttigieg-Klobuchar wing of the Democratic party should spend more time emphasizing how their collective plans will improve access to health care for all Americans while mitigating disruption to the doctor-patient relationship. No one wants to see health systems potentially collapse and patients suffer from even worse access problems than already exist. Change is inevitable, we all demand it, but the ways in which our potential leaders talk about its pace will impact the ultimate durability of American health care reform.

Dr. Vin Gupta is a health policy researcher and pulmonologist. Follow him on Twitter @vinguptamd.