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Won't single-payer health care require higher taxes? (Yes, obviously.) And won't abolishing employer-sponsored insurance face opposition from some of the 160 million people happily on those plans now? (Almost certainly.)

At the debates, in post-debate spin rooms and on Sunday TV show interviews, the Democratic presidential candidates are asked these questions repeatedly as if they are "gotcha" questions.

Then they duck and weave to avoid providing the honest but damning (affirmative) sound bite, instead offering some version of: I can convince voters they'd still come out ahead.

Catherine Rampell mug

Catherine Rampell

But in fact the real third rail of health-care reform -- whether we're talking about single-payer, a public option or anything else -- is the question no one seems to be asking: Will you require doctors to make less money?

The United States spends a lot more on health care than other rich countries, about twice as much per capita. We have little to show for it, given our worse outcomes on key measures such as life expectancy and infant mortality.

Medicare-for-all proponents promise that their plans will cause us to resemble these other rich countries at last -- not only in coverage, but in cost, too. How? By eliminating wasteful spending, which has lately come to mean taking on greedy private insurance companies and even greedier Big Pharma.

We heard this claim from Sen. Bernie Sanders, I-Vt.; Sen. Elizabeth Warren, D-Mass.; and others throughout the debates this week. And look, they're not entirely off base.

The time spent dealing with billing and insurance is the main reason that doctor and hospital administrative costs in the United States far exceed those of other nations. Prescriptions likewise tend to be far more expensive.

So yes, we should try to wring administrative paper-pushing out of the system; and we should try to lower ridiculously high drug costs, particularly for life-saving drugs long off patent, such as insulin.

But even if we could wave a magic wand and reduce both of those line items to what they are in other countries -- which, to be clear, the single-payer proposals on the table may or may not actually accomplish -- that alone still won't bring U.S. per-capita health spending down to what it is in, say, Canada.

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David Cutler, a Harvard economist who has done extensive work on both of these subjects, told me he estimated that even these (improbable) changes would close only about half of the U.S.-Canada gap in per-capita health spending.

So what accounts for the rest of the gap? It's mostly what we pay to providers. Or to quote the late, great health economist Uwe Reinhardt: It's the prices, stupid.

Administrative costs aside, U.S. hospitals charge far more for MRIs, appendectomies and other common procedures than their counterparts abroad.

U.S. primary care physicians and (especially) specialists also make way, way more. The average Canadian specialist, for instance, earns about $188,000, while the typical American specialist brings home $316,000, according to an article last year in the Journal of the American Medical Association.

And unlike insurers, whose profits are effectively capped under current law, there's no ceiling on how much doctors are legally allowed to make.

Of course, while insurers and Big Pharma are popular villains, providers are not. People like and respect their doctors, members of a noble profession who treated their cancer or delivered their babies.

Unsurprisingly, then, the two main Medicare-for-all proposals currently under discussion (authored by Sen. Kamala D. Harris, D-Calif., and Sanders) are both silent about what happens to provider prices. Different assumptions made on this issue help explain the extraordinarily wide range of estimates for how much Medicare-for-all would cost.

Maybe providers would all get paid what they're paid under the existing Medicare system. That's substantially less than they typically receive from private insurance -- which means doctors would make less money than under the current system, and probably some hospitals would close. Or, maybe providers would receive something closer to private insurance reimbursement rates, which would keep their incomes higher.

There are arguments to be made for either approach. Either we can decide to pay U.S. physicians as physicians are paid in Canada, and dramatically reduce the cost of Medicare-for-all (and the taxes needed to pay for it); or we can decide that U.S. physicians are worth spending the extra money on (maybe because we're worried they'd otherwise go into even higher-paying careers, like finance), and the plan gets more expensive.

But either way, candidates have to make a choice about a question that is fundamental to understanding what their plans would do, and whether they add up. So far, they haven't.

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Washington Post columnist Catherine Rampell can be reached at crampell@washpost.com.

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(19) comments

martian2

The U.S. pays its doctors far more than any other country in the world, that is a fact. Many foreign doctors are educated here in this country but go back to their country to serve their citizens, that is their passion and they make far less money. Yes the pay here for doctors is spiraling out of control, and so is the cost of medical school. both must be dealt with if we don't want to bankrupt this country by the most expensive health care system in the world. But hey, who cares, I got mine and the rest of you can get yours or die.(sarcasm)

DMoney

That's right. If you got yours and won't be a burden on others--well done and thank you . I hope you enjoy the fruits of your labor.

oldhomey

Well, D, that is one way to look at it. There is another way to look at it, too. You and I somehow -- mostly by virtue of the accident of birth and being born into a middle class white family that valued education -- we grew up and got a job that provided insurance in the nation that pays twice as much for healthcare than any other country. That terribly high price we pay for healthcare arguably comes at the expense of the tens of millions who are left out of the system, even though most of them work and pay taxes, too. No fruits for their labor, I guess. So you enjoy your insurance plan on the backs of those who do not have it through no actual fault of their own. If we had a system that more fairly administered healthcare as a right rather than a privilege, we would be more in line with all the other great industrial democracies of the world that have been doing this for more than half a century.

oldhomey

Here is another element that we don't hear about doctors and hospitals in this debate: how much do they pay in malpractice insurance now as a percentage of their income, and what would it be in a true national healthcare plan, when those injured by malpractice are going to be cared for medically no matter what for the rest of their lives, an expense that accounts for huge awards in malpractice lawsuits. Doctors complain bitterly in general about how expensive malpractice coverage is. We keep hearing of disgusted doctors quitting and retiring because of this expense. Perhaps this debate will provide a little more clarity on the issue. It certainly is needed.

PhysicsIsFun

In Wisconsin it is very rare to bring forward a medical malpractice case and even more rare to win one. The laws in Wisconsin are such that medical malpractice is not a very likely scenario. I forget all of the details but an attorney friend of mine once explained this to me and my wife. I think it has to do with the limits of liability and high cost of bringing a malpractice suit. They rarely happen in Wisconsin, but they do happen more often in other states.

DMoney

Yes, all the physicians in this country will just happily accept a massive pay cut. This void will be filled by spirit and pride, I'm sure, of the knowledge that all are taken care of. Of course, they would never use their collective billions of dollars to lobby against socialized healthcare. They went to school for almost a decade to help people, not make big money.

PhysicsIsFun

I can speak from personal experience as my wife is a physician who retired in 2016. Yes she made a good salary. Yes she would not have been a big fan of a significant pay cut. She also was a strong supporter of the Affordable Care Act and felt that medical costs were way out of wack. She would have gone along with significant changes in our system it it provided good care for everyone. We have young physician friends with significant school debt (in excess of $100K). Often this debt is paid off by the system who hires them if they stay for a set number of years, but for those who have to pay it off themselves it is a significant economic bite. We could go a long way in providing economic assistance to medical students so they do not have to mortgage their future.



I have observed the healthcare system in Mexico, a much less wealthy country. In many cases it is far more affordable than ours and just as good (except in very rural areas much like here). Most people just need routine care not some miracle super expensive lifesaving intervention. Mexico has that, but they really deliver the everyday care people need to almost everyone without bankrupting the country or its citizens.

PhysicsIsFun

A lot can be said about the salaries of the people who peddle medical devices, pharmaceuticals, insurance and other ancillary materials. Their salaries at time dwarf what physicians make and they do not need to invest years and many dollars into an expensive education. The CEO of the company where my wife was employed made many millions of dollars each year. There were also numerous vice presidents with huge salaries. We have all read about the multi-million dollar salaries of insurance CEOs. I have a physician that I see who probably makes a million dollars a year, He is considered one of the worldwide experts in electrophysiology. He has numerous inventions of 3D imagining software. I believe he deserves every cent he gets, plus he supports progressive causes. So there are salaries besides physicians that can be looked at.

DMoney

I've never been to a Mexican hospital, and since you winter there, you would know. I've heard opposite, but that's probably just from a tourist standpoint. The idea of needing medical attention in Mexico scares the bejesus out of me though.



If your wife honestly would have traded a chunk of her salary for the greater good, fantastic. Very noble. I think she would be the exception to the rule.

PhysicsIsFun

I can tell you that if you fear Mexican hospitals you should give some thought to the hospitals we have here. Two of my friends have died this year after being in what is considered one of the top hospitals in the state. I won't say which it is, but it is in Milwaukee. My wife, a retired physician, helped them because upon discharge the hospital was incredibly remiss in giving instructions and support after surgery. Untrained family members were left to deliver complex nursing care with no help and little training. The follow up from the hospital was so bad they the each got sepsis. One of them had brain cancer, and the confusion in diagnosis was incredibly inept. My wife eventually resorted to calling the primary care doctor and threatening them with legal action. Only after a dramatic emergency incident did the physicians and hospital take her case seriously. The final bill for her care was over one million dollars. My wife was involved trying to assist both families, but the situation became unsafe. In both cases the medical system failed to deliver appropriate care to these 2 individuals.



I can tell you also that we have had friends who were hospitalized in Mexico and received tremendous care at a very reasonable cost. Granted they did not have as serious of a condition as my 2 friends who died, but again my was involved and each received appropriate care was diagnosed and treated properly, was discharged with clear easy to follow instructions. To give you an idea of cost one was in the hospital for 4 days and had a complete G.I. workup with colonoscopy, MRI, labs, G.I. consult, and other tests. The total cost was under $2000, and she had a view of the ocean from her room.

DMoney

I'll also point out, you are talking about socialized education as a way to help fund socialized healthcare. There's two huge industries now socialized. What's next? Food? Housing? Where does it end. Hate to use the slippery slope argument but you just socialized another thing already.

PhysicsIsFun

I hate to burst your bubble but public education is already socialized.

Climatehoax

If Drs make less, than professors have to make less. A Dr I know had over a half million in student loans when she graduated. And no, the answer isn’t college paid for by someone else, (free, as the incorrect term used by liberals)

PhysicsIsFun

As usual you make no sense.

oldhomey

Exactly, Physics.

Climatehoax

As usual liberals can’t link one action with another, the amount of money a Dr makes is related to how much professors make, get it?

PhysicsIsFun

How so? They are two totally different professions.

oldhomey

No, Climate, I don't get it. You would have to come up with a pretty remarkable explanation linking the two, so go to it or hold or retire your argument.

johnnybragatti

The climatedope , another day ,another blackout, in an already mentally ill state. Ya"ll can"t fix stupid...ya'll can"t fix crazy either.Better get back on your opioids.

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