Having spent two years in Oxford as a Marshall Scholar in the mid-1970s, I came back to medical school believing in a national health service; i.e. Medicare for All. But over the next 30 years I learned at first hand that a monopoly can provide access but not quality. When quality isn't job #1, as GM ironically claims, there's no hope for lowering costs or suffering.
The public-sector solution must be fully accountable. Medicare hasn't been and never will be.
My suggestion for the public sector is the Public Health Service: use it for the 50 million un- and under-insured while leaving private-sector insurance and Medicare alone.
The PHS used to care for thousands of Americans. Its last TB hospitals closed in the 1950s. But in 1921, it loaned 57 of its hospitals to the VA after World War I to care for the veterans lying by the roadside. It's time to repay that loan, with appropriate taxpayer-supplied interest, now that the country needs the infrastructure. The thousands of veterans I spoke to in St Louis in the 1990s all supported this idea.
There is nothing more American than the PHS. It was established by Congress in 1789, and can take care of anybody Congress directs it to, including the 50 million un- and underinsured Americans. VA physicians see only a fifth of the patients that private-sector doctors do, 200 instead of 1,000 or even 2,000 in the private sector. Having them work harder, five half-day clinics a week instead of just one, would let them see everybody at little extra expense.
Besides, the VA/PHS has a long-standing tradition of clinical research and teaching. Without it, there would be no academic medicine in the US.
The Secretary of HHS could order the PHS to improve outcomes and lower costs for common diseases, something nobody in healthcare currently does. Medicare doesn't even pretend to. The NIH abandoned clinical research in the 1960s, focusing on "mechanism" ever since. There is no money, for example, to repurpose generic drugs for new disease indications, which is the safest, quickest, and cheapest way to improve outcomes.
I discovered this when I solved dialysis 25 years ago. The VA fired me for it, and Medicare, already Single Payer for dialysis, had no interest in cutting 7% of its budget. Ditto for healthcare globally; dialysis is the main pillar of the lucrative status quo, and how the entire subspecialty of nephrology gets paid:
