From COVID to Monkeypox, Our Health System Failed. We Need Medicare for All.

Racial inequities are emerging in the vaccination and treatment of monkeypox, just as we saw with COVID. In recent weeks, roughly 25 percent of new monkeypox cases have occurred among white patients. Yet more than 33 percent of monkeypox vaccines have gone to white patients (as of September 27).

Financial and logistical barriers to monkeypox care can disproportionately affect patients of color. In New York City, appointments for monkeypox treatment and vaccination, distributed on a first-come, first-serve basis, have disproportionately gone to wealthy, white individuals who have better access to the health care system. The first vaccines were doled out in Chelsea, a mostly white neighborhood, during the middle of the workday on Thursday. Even when vaccines began to be distributed in Harlem (a neighborhood that is 82 percent non-white), appointments appeared to go largely to white residents from outside the community, leaving community members frustrated.

Such disparities mirror larger trends in society. Across specialties, physicians disproportionately spend their time seeing white patients, despite patients of color, on average, having higher medical needs. Due to the legacy of slavery, Indigenous genocide, xenophobic immigration regulations and centuries of racist economic policies, patients of color are more likely to be under- or uninsured, and in general, have lower incomes. Patients of color are also more likely to experience difficulties accessing transportation, or taking paid time off work to access appointments. The latter is particularly important for individuals with monkeypox, which requires prolonged isolation, and whose painful lesions can inhibit the ability to work.

We need explicitly anti-racist policies to repair these harms. Medicare for All would eliminate financial barriers to health care, and in doing so, help address the racial inequities highlighted by the monkeypox pandemic.

Medicare for All would establish a “single-payer” system, in which all U.S. residents would receive health insurance. All U.S. residents would have access to medications, doctor appointments and hospitalizations with low or no copayments. Undocumented individuals could be covered under the current House bill, as to be determined by the U.S. Secretary of Health and Human Services.

Studies show that Medicare for All would have saved 340,000 lives so far during the COVID pandemic, primarily by eliminating financial barriers to care, while saving billions of dollars annually. It’s a rare “free lunch” in economic policy, because savings under a single-payer system far outstrip the costs of expanding coverage. The U.S. spends nearly a third of all health care dollars on administration, approximately $800 billion annually, primarily coming in the form of private health insurance company overhead and profits. Medicare’s fee-for-service plan, in contrast, has 2.4 percent overhead.

Medicare for All could address racial disparities in monkeypox access by making all services free of charge, disproportionately benefiting racial and ethnic minorities. Most Americans would see their incomes rise, not only because premiums and copayments would fall to near zero, but because for the majority of Americans with employer-sponsored insurance, the potential salary that is currently tied up in insurance subsidies would be freed up.

Taken together, these financial boons could disproportionately benefit people of color who are more likely to delay health care because of cost. It’s notable that in the Veterans Health Administration, a single-payer health care system, many racial disparities in health outcomes are mitigated or absent.

When diseases like monkeypox disproportionately affect communities of color, the financial impact on hospital systems is not equal, reproducing structural racism. In general, hospitals primarily serving patients of color earn fewer profits, since these patients are disproportionately uninsured or covered by public insurance, which reimburses less than private insurance. This codifies a perverse financial system in which white lives are more valued than the lives of people of color.

Over the past few decades, this has also led to an arms race among health care systems, which invest in lucrative projects to attract privately insured (disproportionately white) patients, driving up the cost of care for all in the process. Meanwhile, clinics that serve people of color remain underfunded.

It doesn’t have to be this way. Medicare for All would establish a financing system called “global budgeting” that could allocate resources based on need, similar to how we currently finance fire departments. It’s a common-sense approach that aligns dollars with need. Safety net and rural hospitals, which are currently closing at record rates, would see boosts in revenue, and unnecessary or wasteful spending would be curtailed. This would be a boon for clinics which focus on lower reimbursing areas, like primary care, mental health, and yes, infectious diseases.

The early days of the monkeypox pandemic have been plagued by supply chain and logistical challenges. Vaccines remain scarce and maldistributed. Contact tracing and testing have been challenging. Medicare for All wouldn’t, in and of itself, fix all of these problems, but it would enable a national electronic medical record, mitigating logistical hurdles that result from our byzantine, multi-payer health system.

For example, in 2020, Taiwan’s lauded initial response to COVID would not have been possible without its single-payer system and national health insurance database, which streamlined contact tracing and communication.

There will be more pandemics after monkeypox and COVID-19. Narrow, disease-specific measures, such as those passed in 2020 making COVID hospitalizations free, expire with time, serving only as Band-Aids. Other incremental reforms are politically attractive, but mathematically infeasible, as they do not come with the administrative savings of a single-payer system.

There is a saying in medicine that the United States does not have a “health care system,” we have a “sick care” system. Among wealthy nations, the U.S. stands out for its uniquely reactive, profit-driven system which is disinterested in prevention. The monkeypox pandemic makes this all the more clear, and also sheds a light on structural racism in our health care system. By advocating for Medicare for All, we can build a better system, fundamentally reoriented to justice and public health, one that prioritizes people over profits and takes a necessary step toward confronting racial inequities in our society.