Listening to the debates, both Republican and especially Democrats, one wonders if what Bernie Sanders proposes can come true. The commentary in The Week magazine by Paul Krugman from the New York Times poses that very question. He states that the Affordable Care Act is “what engineers would call a kludge.” He any many other believe that it is an “awkward, clumsy device with lots of moving parts, yet it has largely succeeded in what it was designed to do: make health insurance available to all Americans and reduce the number of uninsured by 20 million. But because it’s messy and imperfect, should Democrats “try for something better”- a single-payer, Medicare-type program covering everyone, as presidential hopeful Bernie sanders suggests?” His opinion as well as many other candidates, Senators, Congressman and voters, is that there is zero chance of enacting such a proposal. He points out and it was emphasized on an interview with Senator Sanders, that the single-payer, Medicare-type scheme would require large tax increases on not just the wealthy but also the middle class; even if these taxes were offset by eliminating premiums, as Bernie suggests. Millions of Americans who would lose the good health insurance they currently get through their jobs would rebel….maybe! Also, because of the limitations in the system with long delays in physician visits, treatment and surgical procedures, care of the patient would suffer. You have to understand that I believe that a single-payer system may still be what the future has as our eventual health care system even if the Democrats don’t win the White House.

U.S. Sen. Bernie Sanders on Sunday detailed a Medicare-for-all plan to provide better health care for all Americans at less cost. Sanders laid out his health care plan and progressive tax reform proposals in South Carolina where he and former Secretary of State Hillary Clinton and former Maryland Gov. Martin O’Malley were to take part on Sunday night in a nationally televised debate in their contest for the Democratic Party presidential nomination.

Joyce Frieden wrote in MedPage Today “Universal health care is an idea that has been supported in the United States by Democratic presidents going back to Franklin Roosevelt and Harry Truman,” Sanders said. “It is time for our country to join every other major industrialized nation on earth and guarantee health care to all citizens as a right, not a privilege.”

The proposal would expand Medicare, the popular and successful health care program for seniors, and build on the success of the Affordable Care Act, which Sanders helped craft. Patients would be able to choose their own doctors and receive comprehensive care for everything from hospital stays to emergency room visits to primary and specialty care.

Sanders’ Medicare-for-all plan would save $6 trillion over the next 10 years compared to the current system, according to a detailed analysis by Gerald Friedman, an economist at University of Massachusetts at Amherst who is a leading expert on health care costs.

In a nation that now spends $3 trillion a year on health care – nearly $10,000 per person – Sanders’ plan would save consumers money by eliminating expensive and wasteful private health insurance. The plan would save taxpayers money by dramatically reducing overall health care costs and bringing down skyrocketing prescription drug prices which are far greater in the United States than in any other country.

The typical family earning $50,000 a year would save nearly $6,000 annually in health care costs, Friedman calculated. The average working family now pays $4,955 in premiums for private insurance and spends another $1,318 on deductibles for care that isn’t covered. Under Sanders’ plan, a family of four earning $50,000 would pay just $466 per year to the Medicare-for-all program.

Businesses would save more than $9,400 a year in health care costs under Sanders’ plan. The average annual cost to the employer for a worker with a family who makes $50,000 a year would go from $12,591 to just $3,100.

The shift to universal health care would be paid for with a 2.2 percent health care premium (calculated under the rules for federal income taxes); a 6.2 percent health care payroll tax paid by employers; an estate tax on the wealthiest Americans and changes in the tax code to make federal income tax rates more progressive.

Under the plan, individuals making $250,000 to $500,000 a year would be taxed at a rate of 37 percent. The top rate, 52 percent, would apply to those earning $10 million or more a year, a category that in 2013 included only the 13,000 wealthiest households in the United States.

Additional savings would be achieved from reducing outlays for taxpayer-supported health care expenditures. But we must not forget that we are using present day tax figures. Sanders and all progressives/socialists want to give away to those “in-need” and tax everyone else at huge increases in our income, payroll taxes and…wait…for it…federal sales tax or what the Europeans call Value Added Taxes. Just beware someone has to oay for the programs.

But what would it mean for doctors?

Proponents argue that a single-payer system — in which healthcare is financed entirely by the government through higher taxes on Americans — would have several advantages for providers. “If we look at what happened in Canada,” which went to a single-payer system in 1966, “Canadian doctors are doing quite well,” Steffie Woolhandler, MD, MPH, a co-founder of Physicians for a National Health Program, a lobbying group for single-payer, said in a phone interview.

“Their incomes on average are a little less than [doctors] in the U.S., but just a little less. They don’t have to pay their own healthcare costs, and the amount of time spent on [administrative tasks] is a fraction of what American doctors have to spend on administration.”

In addition, if the U.S. moved to single-payer, “doctors and hospitals will all be paid according to same payment rules — and I think this is a very important step because one of the problems we have now is multiple tiers of payment, and that creates incentives for doctors and hospitals to prefer one type of patient over another based on their insurance,” said Gerald Kominski, PhD, director of the Center for Health Policy Research at the University of California in Los Angeles, in a phone interview. “That’s been true for years and it has gotten worse over the last few decades.

“Now that we have the Affordable Care Act, it adds another tier. I don’t have good research evidence yet, but I can tell you anecdotally that ACA insurance is paying closer to Medicare [rates] or below, as opposed to rates more like private insurance.”

The guaranteed payment would also relieve some worries, said Harold Pollack, PhD, Helen Ross Professor at the School of Social Service Administration at the University of Chicago, in a phone interview. “Most physicians want to know they’re getting paid and that patients can get the healthcare they need without suffering terrible financial consequences.”

But it wouldn’t be all roses. “My colleagues and I think this is nothing more than a government monopoly and it would have economic consequences as any government monopoly would,” Robert Moffit, PhD, senior fellow at the Center for Health Policy Studies at the Heritage Foundation, a right-leaning think tank in Washington, said in a phone interview.

“Monopolies are bad because they are basically vast concentrations of economic power in very few hands,” he continued. “We are talking about the government controlling virtually everything because it will be the single provider of a particular set of services, and that means … every decision dealing with the system is not simply an economic decision or a medical decision, ultimately it’s a political decision.”

“You have to make political calculations, like how much you are going to spend, and when you get down to doctors and hospitals, what the reimbursement will be and will not be.”

In addition, a single-payer system probably would mostly use fee-for-service and might derail current efforts to pay for value rather than volume, according to A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan in Ann Arbor.

“There’s a very good reason for saying [patients] should have higher cost-sharing for a drug that treats toenail fungus versus one that treats cancer,” but the single-payer plan proposed by Sanders would make all covered services free of copayments or deductibles, “which is the farthest thing from value-based insurance design,” he said in a phone interview. “Single-payer says ‘You’re in or you’re out’ and that’s very problematic to me.”

Having just one entity making the rules about which services get paid for has its pluses and minuses, said Katharine London, MS, a principal at the Center for Health Law and Economics at the University of Massachusetts Medical School in Charlestown. “If there were one plan and everybody had one set of rules, the good part of that is that doctors could focus all their efforts on ensuring that those rules make sense; on the other hand, if there’s a rule they don’t like, that affects all patients and they can’t go around it.”

London was involved in developing a proposal for a single-payer plan for the state of Vermont — in the end, Vermont governor Peter Shumlin (D) ended up dropping the idea. “It was frustrating because we did come up with an option that was affordable,” she said in a phone interview. “But they had to bury it because of politics. The public financing is a heavy lift — the idea that you’re going to pay for your healthcare through your taxes.”

The best way to get to single-payer — if the country decided that was what it wanted to do — would be a gradual approach, according to Pollack. That might mean, for example, having a “public option” that allows people to buy into the Medicare program voluntarily, and then eventually moving everyone into it. “People are saying that if you believe in single-payer, you should support the public option because it gets us from here to there and it’s cheaper than [private coverage] in a lot of ways,” he said.

The idea of a public option was floated when the ACA was passed, but it was eventually dropped from the bill because it was too controversial, Pollack noted. “Unfortunately, we ended up with these co-ops, which are a very weak substitute. I’d like to see us return to the public option idea because it has some real value.”

Like anything, when it comes to implementing a single-payer system, the devil will be in the details, London said. “It depends on the details of how it’s implemented; I don’t think how the plan is financed affects the practice of medicine necessarily. If you could change the system so doctors could practice medicine and spend time with their patients, I think that’s really what doctors want.” But remember, with a single-payer system, there are very few choices and one does not have control of waiting times to see a physician, as if they do now, as well as the limitations regarding extent of care and treatment protocols and end-points.

AND, if you don’t think that we are really on our way to a system like Sanders is touting pay attention, especially you doctors out there, to this Bill proposal in Hawaii:

Hawaii lawmakers are introducing a bill to require all doctors practicing in Hawaii to treat Medicare patients.

Democratic House Speaker Joe Souki introduced the bill Friday, saying it would ensure that all people get medical treatment, regardless of their income. Souki says that if passed, physicians who refused to take Medicare patients wouldn’t be able to reapply for their state medical license, which must be renewed every two years.

Souki says he expects push back from physicians who complain about Medicare’s low reimbursement rates.

Hawaii’s Medicare enrollment data shows a 30 percent increase from 2010 to 2012 in the number of seniors relying on Medicare for health insurance.

So, with a heavy heart, I once again warn the voters, the doctors and…. the patients, to beware of who you vote for and therefore your future. And for those of you who shout out that you are not going to vote, remember, you are then part of the cause of the eventual problem and have no right to complain.

I used a cartoon, which should bring back memories of former election years….Hope and Change and an increasing/enlarging government with less individual control of our lives. Dangerous from any point of view!

Educate yourselves and chose the candidate who will support and improve the American democratic, free-market system…Not the Socialist system, which will lead us down the rabbit hole!