In previous columns we have discussed the moral imperative for Medicare for All,1 and how Medicare for All can decrease US health care spending.2 Here we address frequently-asked questions of how Medicare for All would affect patients and family doctors. We draw on our health policy experience in government, payer and health care systems, as well as personal experience in Taiwan and the United Kingdom, both nations with single-payer systems.
What Will Happen to Patients’ Access to Primary Care?
With universal coverage, patients will have free and unfettered access to primary care. Visits from previously uninsured patients and the removal of cost barriers would increase primary care demand, as we witnessed with Medicaid expansion in the Affordable Care Act.
Unfortunately, we also anticipate that the increase in demand would further stress the current primary care capacity in many areas. In Taiwan, for example, doctors often see over 100 patients per day.3 As demand exceeds physician supply, more patients will receive care from advanced practice clinicians.
What Will Happen to Patients’ Access to Specialty and Hospital Care?
Removing cost barriers will enable better access to specialty and hospital care. Affordability and reductions in medical bankruptcies are a win.
However, some patients may have a harder time getting specialty services. In most single-payer systems, specialty and hospital services are constrained by a primary care gatekeeping function.
A single-payer system will limit high-cost services by reducing how much they pay for these services. Hospital and specialty providers may downsize or close because of lower volumes and lower reimbursements. Similarly, access to novel and high-cost prescription medications may be constrained. As observed in Taiwan and the United Kingdom, many high-cost treatments and medications are excluded or subject to slower approval processes.
What Will It Be Like to Practice Family Medicine and Primary Care?
In many ways, clinical practice would improve under Medicare for All. There would be greater certainty about patients’ coverage and physicians would have greater confidence that patients could access tests, treatments, and other services. There would be much less administrative burden related to billing and contracting, which physicians are currently responsible for with multiple payers and purchasers.
On the other hand, family doctors will likely face longer work hours and higher patient volumes, based on the increased primary care demand. In the setting of a fixed national budget for health care, it is unlikely that reimbursement and physician payment will increase in response.
How Will We Address These New Challenges That Come With Medicare for All?
Although Medicare for All solves problems of coverage, cost, and administrative burdens, primary care will face a different set of challenges in patient access and the physician practice experience. Other nations with single-payer systems also struggle with these issues.
One answer will be to increase the primary care workforce. Under Medicaid expansion, new programs like the Teaching Health Centers were created to increase the supply of the primary care physician workforce.4 New programs will be needed to train more primary care physicians and advanced practice providers, and to target rural and underserved communities.
New models of care delivery will need to optimize physician time and space for complex care coordination, care team leadership, and patient and caregiver engagement. Other care redesign innovations, such as telemedicine and remote monitoring, will use technology and artificial intelligence to improve access to care. Redesign would need to be supported by value-based and other incentive reforms to reduce volume-based payments.
Regardless of the outcome of this year’s presidential election, the debate over Medicare for All has highlighted persistent problems in American health care. A single-payer solution addresses some, but not all of these problems. Family physicians, and our learners, deserve a clear understanding of the issues and implications of dramatic change like Medicare for All, and the consequences of doing nothing.