The following is adapted from “ The Road to Medicare for All: A Call to Action ,” published by Routledge.
In the early morning hours of Dec. 4, 2024, the CEO of UnitedHealthcare Inc. was gunned down outside the Hilton Hotel in midtown Manhattan in New York City. The CEO was on his way to the company’s annual investor conference. The police found the words “Delay,” “Deny” and “Depose” carved into bullet casings at the scene.
The public reaction was swift and overwhelming. People took to social media to describe stories of mothers, fathers, spouses, children and friends who had died from treatable illnesses, dead they said because UnitedHealthcare or other health insurance companies had either denied the lifesaving care doctors had prescribed to their loved ones or had endlessly delayed approval of lifesaving treatment.
Physicians posted stories of the hours they spent on the phone, seeking to convince insurance companies of the necessity of the care they had prescribed for patients. The providers detailed spending countless hours advocating for their patients to insurance company doctors who had little or no expertise in their area of medicine but with the power of literal life or death to authorize or deny payment for the prescribed treatment. The frustrated providers recounted incidents of being on hold for hours and transferred among insurance executives in what felt like perpetual loops.
Virtually all treatments are prohibitively expensive without insurance.
When the treating physicians finally got through and were told they had to schedule a time to talk, the time for the so-called peer-to-peer conversation was solely at the convenience of the insurance company doctor, with no concern for the schedule of the treating physician. One doctor talked about a particular insurance company that told doctors they would get a call back but were not told when or from what number. They were told, though, that if they didn’t answer, the claim would be denied.
Then came the denials. UnitedHealthcare and other insurance companies are not required to disclose their denial rates, but anecdotal evidence and lawsuits suggest that the rates are high. And denial is a life-and-death matter. Virtually all treatments are prohibitively expensive without insurance. One TikTok contributor described receiving six months of chemotherapy for her dangerously advanced, stage 4 cancer, only to receive a letter from her insurer saying it would no longer pay for the treatment. She explained in her post that the treatment cost $15,000 every three weeks and the alternatives she had tried before starting the current regimen had done nothing. Only the current treatment prescribed by her oncologist worked.
America’s outlier healthcare system: expensive, wasteful, complicated, deficient
The delay and denial of lifesaving care doesn’t happen in other wealthy countries the way it does here. The United States is an outlier. Its healthcare is the most expensive in the industrialized world, while its outcomes rank at or near the bottom. Thirty million Americans — almost 10% of the population — have no health insurance whatsoever. Millions more are underinsured. Though they have health insurance, it does not cover the care they need at a cost they can afford. Even those with supposedly adequate coverage often have high deductibles, causing some to delay care until their health issues are too severe to ignore. The problem is that in the United States, healthcare is implicitly treated like a commodity, like the latest iPhone, or simply a service, like plumbing or electrical work in a home. Of course, healthcare is not just another commodity or service. It is literally a life-and-death matter.
No matter where you live, everyone should have high-quality healthcare.
Unlike the government, which has the power to tax, can control its currency and is not going out of business, companies can only stay in business if they turn a profit. That means that health insurance corporations must ensure that they don’t pay out more in benefits than they collect in premiums, and the premiums can’t be too large or their customers will go elsewhere. To make the numbers work and earn a large enough profit to keep shareholders happy, these companies must seek to entice those who are healthy and therefore not in need of healthcare, by offering benefits like gym memberships. They must carefully screen to cherry-pick the healthiest of the population and avoid covering those likely to need expensive care. If their enrollees do get sick, insurance companies can restrict what treatment patients are able to get by limiting the doctors and hospitals that are in their networks. The companies can delay or even deny prescribed treatments, if they are expensive and supposedly uncertain of success, by requiring pre-authorizations. Indeed, insurance companies refused to insure anyone with preexisting conditions — such as birth defects, pregnancy and job-related injuries — until the 2010 Patient Protection and Affordable Care Act prohibited that discriminatory practice designed to reduce expenses and bolster profits.
In short, private companies must cover their costs to remain in business. That too often translates, in the case of health insurance corporations, to denying payment for doctor-prescribed medical care. Like our court system, police and fire departments, public libraries and public schools, high-quality healthcare should be available to everyone in America as a right—automatic and free of charge when we need it. Rich or poor, sick or healthy, old or young, no matter where you live, everyone should have high-quality healthcare.
The obvious solution to our broken healthcare system
The way for health insurance in the United States to be universal, affordable and efficient is to make the federal government the insurer. Insurance is most cost-efficient and reliable when the risks can be spread across as broad a population as possible and when people cannot delay purchasing the insurance until the moment they know they are getting sick — a practice known as adverse selection. Only the national government has the power and ability to establish a nationwide, universal risk pool, with mandatory participation, making adverse selection impossible. Furthermore, when the federal government administers the insurance, overhead is minimized. Instead of highly paid CEOs wielding power over our healthcare, hardworking, modestly paid civil servants are in charge. Instead of unaccountable private actors in control, federal employees, subject to transparency and oversight, are the administrators. Moreover, other costs, like advertising and marketing, are unnecessary.
Fundamentally, the government is not seeking a profit for shareholders or high salaries for executives. In addition, there is only one payer, producing more efficiency and less waste. Consequently, all of us, collectively through the government, can provide healthcare less expensively and more efficiently for everyone. […] Profit should have no place in our healthcare system. Instead, there should be a single insurer that can pay for the most efficient care equitably and universally. We would spend less as a nation and have better health outcomes.
We know it works because an American institution has been paying for healthcare efficiently and fairly for over 60 years: Medicare . To be clear, the solution is definitely not the vastly inferior, misleadingly named Medicare “Advantage.” […] The solution is traditional Medicare as it was designed and enacted in 1965, with it improved and expanded to everyone.
Medicare works. Americans overwhelmingly agree. After living with private health insurance or, worse, no health insurance at all, your 65th birthday is eye-opening. That birthday brings Medicare. Once you enroll in Medicare, you generally have no claims to fill out, no insurance companies to contact. It is comparatively simple.
The government is not seeking a profit for shareholders.
The vision of Medicare for all is for everyone to have that simplicity and much, much more. In addition to expanding it to everyone, Medicare should be improved. Today, those with traditional Medicare who can afford supplemental private insurance coverage (colloquially known as Medigap, because it fills in the gaps) generally must purchase it to control their costs. That will be in the rearview mirror under Improved Medicare for All. All premiums, co-pays, co-insurance and deductibles should be eliminated.
The vision is for cradle to grave, comprehensive healthcare coverage for everyone in America, automatically. It means better protection for everyone at lower cost — including for those covered under today’s Medicare. Improved Medicare for All means going to the doctor of your choice, without first checking to see if your preferred practitioner is in your insurance network. With Improved Medicare for All, there is essentially one big network of virtually every doctor and hospital in America. The result? Guaranteed healthcare with the provider of your choice, anywhere you happen to be, without the stress of dealing with private insurance companies. […] So how do we make that vision a reality? Medicare provides protection to the grave. But not from the cradle. At least, not yet. We are the wealthiest nation in the entire world at the wealthiest moment in our history. We are much wealthier than we were in 1965, more than a half century ago, when we enacted Medicare for those age 65 and older. We are much wealthier than we were in 1972, when we extended Medicare coverage to people with serious, work-limiting disabilities. Seniors and people with disabilities are the segments of our population who, on average, have the highest medical costs and the most frequent need for care. Covering the rest of us should be easy. The politics make it hard, but it is achievable. As the title of the book makes clear, we are on a journey.
Every chapter contains aspects of the discussion of how we got here — the nation’s history of healthcare — in order to provide context for the following points: Chapter 2 explains that the nation was on a slow path toward a single-payer system (essentially Medicare for All) during the first three-quarters of the 20th century despite the strong opposition of powerful forces. Then, though, as Chapter 3 details, the powerful forces became more organized and proactive. They succeeded in stopping the push for Medicare for All in its tracks. Indeed, they did not just halt progress; they partly reversed it. Perhaps most damaging, mainstream Democratic Party leaders lost sight of the destination. Opportunities were lost as a result. Chapter 4 explains that where we are now is a result of having failed to enact a single-payer system. It discusses the flaws and unsustainability of the current patchwork system. The chapter explains that Democratic leaders, in the face of the election of President Ronald Reagan almost a half century ago, gave up on the destination. That was unfortunate. It has led to where the nation finds itself today. Continuing down the current road, simply tinkering with the present system, is unsustainable. Exiting the current road and getting back on track is essential.
Chapter 5 explains what the right road is. It reminds us what our North Star was prior to 1972 and what it should be again. It lays out the vision of a single-payer Improved Medicare for All system. It also explains that questioning the affordability of Medicare for All is misguided. The correct questions are: 1) since the new system will save money, how should we divvy up the savings? and 2) given the complete unsustainability of the current system, how can the nation afford not to enact Improved Medicare for All? Monied interests have prevailed for the last half century, but history is not destiny. Replacing our current Rube Goldberg-style, overly complicated, dysfunctional healthcare system with a straightforward, superior system of Improved Medicare for All won’t happen without determined effort. History teaches that the commercial health insurance industry fears losing its business and will fight every initiative that jeopardizes those profits. The pharmaceutical industry will fight any initiative that will cut its exorbitant profits. Historically, physicians and hospitals have opposed government-provided health insurance. Given the powerful forces arrayed against Improved Medicare for All, its failure so far to become the law of the land is not hard to understand. Indeed, because healthcare is so crucial to all of us, it is easy to convince us that we will lose, not gain, from Improved Medicare for All. It is not hard to scare us into thinking that it is something foreign, un-American, inconsistent with the nation’s values and harmful for us as individuals.
All premiums, co-pays, co-insurance, and deductibles should be eliminated.
The concluding three chapters answer all of these challenges and fears. They provide the tools, including a road map, to finally reach our destination. Chapter 6 highlights the politics and how a winning coalition can be forged. It discusses why the organizations that represent hospitals and physicians may be convinced to end their opposition to Improved Medicare for All and join the other supporters working to enact it. Whether that happens or not, it is crucial to understand that the forces arrayed against Improved Medicare for All have been defeated in the past and they can be defeated again. The response to the murder of the UnitedHealthcare CEO is but one example spotlighting that the American people are both united and ready. The answer lies in numbers, active involvement, and determination. To the extent the electorate is engaged and clear-eyed, victory is not only achievable; it is inevitable. Chapter 7 alerts supporters to at least some of the disinformation that opponents will use to stymie and depress those engaged in the effort. The chapter adopts the premise that forewarned is forearmed. Finally, Chapter 8 provides specific actions that readers may take to join the winning fight. Universal healthcare is a fight we can and must win. And a winning fight it will be.
It may appear that the worst time to engage in this fight is now, in the shadow of the November 2024 election , when Donald Trump was returned to office together with a Republican House of Representatives and Senate. The Supreme Court is controlled by conservative forces hostile to a domestically active federal government, and the entire judiciary will be even more conservative after the first few years of a Trump presidency. Yet this is the perfect time.
As polarized as the American people currently are, we are overwhelmingly united in our support for Medicare, as well as Social Security. Expanding both programs can lead the way to reunite the United States. Together, we will win. We must. Medicare for All won’t happen without a fight, but it is a fight we can win. It is a fight we must win. Our lives literally depend on it.
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Medicare for All: Where We’re Going and How We’re Getting There
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