Is Bernie Sanders the new health care pragmatist?

It is hard to find someone I agree with less than Bernie Sanders, particularly in my own area of health care. But increasingly, I find myself agreeing with him on significant health care issues.

Is Bernie Sanders becoming the ultimate health care pragmatist — wanting good progress even as his deepest health care desires do not seem achievable?

Things seem to be pointing this way, especially with his recent announcement regarding the need to tackle the primary care crisis. The Kaiser Family Foundation, perhaps the most respected health care analysis foundation out there, looked at Sanders’ arguments and determined that what he was saying were mostly true.

Sanders recognizes that his hope for Medicare for All is nearly impossible for now.  He told community health advocates that “We are far from a majority in the Senate. We have no Republican support…and I’m not sure that I could get half of the Democrats on that bill.”

I don’t believe Sanders’ Medicare for All would be a good thing for the country. It just wouldn’t be wise to base our health care on the dilapidated fee-for-service system. It would be terribly expensive as well. I believe affordable universal access via a private delivery system offers the best chance at reducing costs and improving quality. It would have a strong accountability regime through HHS and CMS.

But Sanders is right on a number of things that he wants to make progress on. His pivot from Medicare for All to issues of common ground bring me closer to him, also offering hope Congress could make progress on some health care issues.

Sanders is right that we clearly have an uninsured crisis. Despite the passage of the Affordable Care Act, at least 25 million Americans still do not have consistent health care coverage. And that number will increase due to the fallout from the reintroduction of Medicaid redeterminations. Already, about 4 million have lost Medicaid coverage. Based on various private and government estimates, that number is projected to hit at least 15 million.

How many will successfully move from Medicaid to employer coverage, state children’s coverage, and the exchanges is unknown. But historic trends and some preliminary evidence suggests conversions may not be good, so the ranks of the uninsured will grow by millions. Sanders understands that up-front and affordable coverage ultimately saves money and improves outcomes.

Sanders has always pushed the concept that we not only have an uninsured crisis but an underinsured one. If we already have roughly 25 million who are classified as uninsured, plus anticipated redeterminations, you can almost triple that number to come up with those who will be uninsured or underinsured. The underinsured may have coverage, but there are critical gaps, and their insurance is essentially unaffordable, dissuading people from seeking out the care they need. As with the uninsured, it leads to greater costs as disease states or conditions exacerbate.

Sanders’ latest push is to bolster access to primary care through significant programmatic spending. About $100 billion over five years would be spent to expand community health centers as well as provide training for primary care doctors, nurses, dentists, and other health care professionals. 

As a Republican, I tend to look suspiciously at more and more government spending, but this would be a wise investment. Other developed countries tend to perform much better on outcomes because they emphasize prevention, wellness, and care management. Our system is not designed this way. It emphasizes expertise at the specialist and facility level and discourages primary care investments.

What’s more, we do have a physician shortage that will become worse if we do not act. It will hit almost all areas of specialty, but primary care may fare worst.

Last, areas of low income, especially areas with significant minority representation, tend to have the biggest challenges establishing a nexus between patient and primary care provider.  A lot goes into that, but availability of physicians is an important part. So intervention is needed. While CMS is trying to change behavior via reimbursement in government programs, that will not be enough.

So kudos to Sanders for seeking to hone in on areas of common ground to fix our health care system. The primary care crisis is an area that is ripe for bipartisan work.

Marc S. Ryan is a veteran health plan and health care technology executive. He is the author of The Healthcare Labyrinth.