It’s a new season.
The federal government re-opened this week after a record-breaking shut-down. Democrats gained control of the U.S. House of Representatives, feeling newly emboldened after the dispute about a border wall. A gaggle of 2020 presidential hopefuls has revealed themselves in recent weeks, lining up to be, arguably, the most liberal class of contenders ever. And finally, one independent is positioning himself as the freshly brewed “Grande” candidate to President Trump’s “Venti.”
In light of this new momentum in politics, the discussion has recently returned to the topic of health care. With a divided Congress, the dialogue is mostly theoretical, defining what each side would like to see happen and revving up their respective voters. But with a big presidential election looming, staking out these positions now is also designed to warm up the public for a more intense debate over our endlessly befuddling health care system.
Perhaps the boldest position that has been staked out is Medicare-for-All. This is the name given to a set of proposals for universal health care that build on our existing Medicare system. Most policy-makers think of this as “single-payer” health care, even if Medicare has a wide mix of private insurance thrown in. Policy semantics aside, the fundamental idea behind the proposals is that the government would become a bigger player in the financing of health care.
Branding matters. Interesting polling shows that people react with a stomach-ache to the term “single payer” but get overwhelmingly warm and fuzzy about Medicare-for-All. In those latest data, more than 80% of the population indicated support for the latter. The term socialized medicine–which is not an accurate description of Medicare-for-All–ultimately polls the worst (probably worse than doing the dishes had that been asked) and could be the nomenclature used to derail it.
Perhaps the biggest challenge, however, is providing information about the idea of Medicare-for-All to the nearly 50% [pdf] of the U.S. population that reports not having heard anything at all about it. On the other hand, this could be a unique opportunity to define the brand for a relatively clean slate. The first to define Medicare-for-All and do so in an appealing way may have the advantage.
Different Paths to Medicare-for-All
In the last Congress (the 115th), legislators proposed no fewer than 8 bills expanding the role of Medicare. These range from single-payer systems that nearly abolish the role of the private insurance sector to more incremental changes that instead expand eligibility to more people. The Kaiser Family Foundation has published a thoughtful analysis [pdf] of the various approaches, but here is a quick look at the options:
A single national health insurance plan was proposed in 2017 by Sen. Bernie Sanders (S. 1804) [pdf] and Rep. Keith Ellison (H.R. 676) [pdf]. Co-sponsored by 17 senators, including Elizabeth Warren, Kamala Harris, Kirsten Gillibrand, who are all candidates for president), and more than 50 Representatives, these bills would create a single national Medicare program with new dental and vision benefits, eliminate most out-of-pocket costs, and give states some flexibility to add covered services. The House version allows for some non-profit HMOs to play a role, but any for-profit insurance is only allowed to cover non-Medicare benefits (e.g., cosmetic surgery).
A public option based on the Medicare program has been proposed in multiple forms, including one by Sen. Sheldon Whitehorse (S. 194) [pdf] and Rep. Jan Schakowsky (H.R. 635) [pdf] called The Choice Act. These bills offer individuals (and some small businesses) the option to shop on their state’s health insurance exchange and pick Medicare as an option. This version of Medicare, however, would be subject to the rules of the state exchanges, including requiring copays, deductibles, and co-insurance. The premiums are expected to be less expensive than private insurance because of Medicare’s low administrative costs and, essentially, non-profit status.
An optional buy-in to the Medicare program starting at age 50 or 55 is the focus of bills by Sen. Debbie Stabenow (S. 1742) [pdf] and Rep. Brian Higgins (H.R. 3748) [pdf]. The idea behind both programs is to incrementally increase the eligibility for Medicare by lowering the age requirement. Both programs establish a single national premium that each individual would pay to buy-in to the program, and use the state health insurance exchange rules and procedures. Interestingly, in the House version, employers could contribute to the premium if the Medicare plan was chosen by eligible employees.
In California, An Opportunity
The state of California has toyed with the idea of single-payer health insurance for decades. With almost 40 million people in the state, the implications of embracing universal health care would be dramatic. The most recent bill introduced by CA Sen. Ricardo Lara, called The Healthy California Act, was embraced by several major unions, but widely panned for its lack of clarity about how it would be funded. One legislative analysis found it would cost the state $400 billion [pdf], which an analysis in the New York Times pointed out is more than double the state’s budget.
Still, Gov. Gavin Newsom, who took office the month, is an advocate of single-payer and has energized discussion about its future. This is the first time that a Governor of the state has been openly and actively supportive of taking such steps. However, the idea still faces the challenges of integrating Medicaid and Medicare funds, disempowering (or dismantling) a vastly large private insurance sector, and dealing with large private employers who have chosen to self-insure their workers, and who are protected by federal law to some extent from participating in a single-payer plan..
Medicare for All vs. Medicare for More
Given the divided U.S. Government, states such as California with single-party control are likely to be where any major health policy changes will be made in the next few years. But the idea of Medicare-for-All appears to be gaining some momentum. The extent to which legislators and presidential candidates embrace sweeping changes or more incremental expansions of eligibility (dubbed Medicare-for-More), is now up for legitimate political debate.
This is progress. A decade ago, asking legislators (much less presidential candidates) whether they supported Medicare-for-All would have led to silence. A silence quieter than the Smithsonian during the latest government shutdown.
Gregory Stevens