Medicare for All Would Be Expensive for All

One reason for the high costs is that smart college graduates in the U.S. have more options than their peers in the rest of the world. They can make a lot of money relatively quickly on Wall Street or in Silicon Valley rather than subject themselves to the many years and long hours of medical residency. Correspondingly, physicians' salaries have to be high in the U.S. order to supply the number of doctors the system demands.

So cutting the reimbursement rate without taking steps to otherwise increase the number of physicians would make the current shortage worse. Instead, the U.S. could take steps to increase the number of immigrant physicians, or pressure medical schools to admit more students or lessen the demands they put on young residents. Such steps would be controversial and face public opposition. Yet they may be necessary regardless of whether Medicare for All actually comes to pass.

Another reason for the high costs is that hospitals in the U.S. face very little competition on costs. One recent study examined health care mergers and acquisitions between 2007 and 2013. It found that, once a doctor's practice was acquired by a new owner, prices rose nearly 14 percent. Some of these higher costs reflect a greater emphasis on patient comfort; U.S. hospitals have more private rooms than those in the U.K. or Canada. But some seem to be the result of simple monopoly power.

Working to break the monopoly power of U.S. hospitals is worthwhile goal — one that advocates of Medicare for All may even share. But the history of U.S. health care policy is one of hospitals steadily gaining more power, not less. For example, 35 states require a potential hospital to obtain a "Certificate of Need" before it can open a new facility, and the Affordable Care Act has made it more difficult for physicians to open competing hospitals.

These policies are specifically designed to limit competition and are demanded by large hospitals, which fear that expanding coverage would saddle them with more low-income patients who use Medicaid — which, like Medicare, reimburses at a lower rate than private insurance.

If coverage is expanded through Medicare for All, then the demands for this type of protection would only increase. That would mean less competition and higher prices. Surely even supporters of Medicare for All would agree that this would not qualify as an improvement to the U.S. health care system.

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Karl W. Smith is a former assistant professor of economics at the University of North Carolina's school of government and founder of the blog Modeled Behavior.

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