Digging into Medicare for all
Now that the 2018 election has swung control of the U.S. House of Representatives from right to left, some progressive Democrats are pushing for a vote in the new Congress on Medicare for all, a national health insurance program covering all Americans without charging premiums, deductibles or co-pays. They seem to have the public on their side, at least conceptually: This summer, a poll by Reuters-Ipsos found that 70% of Americans — including 52% of Republicans — favored the idea of Medicare for all.
Some moderate Democrats have pushed back, noting that such a vast expansion of Medicare doesn’t stand a chance of passing the Republican-controlled Senate, let alone being signed into law. There are better reasons, though, for backers of universal coverage not to rush a Medicare-for-all bill to the House floor. There are a host of complexities that emerge once the debate moves past the title and tackles the details, many of which haven’t yet been discussed, let alone agreed upon.
A “single-payer” system would accomplish several things the ACA cannot: Providing fully portable coverage to all Americans, eliminating the threat of ever-rising premiums, and slashing the administrative costs and paperwork burdens of the current system. Bringing all Americans into one risk pool would also spread risk and cost far better than the ACA does.
Critics of Medicare for all (or any version of single-payer) have focused on the enormous tax increase that would be required to make the switch. One widely cited estimate put the cost at $32 trillion over 10 years, although the study’s author conceded that the switch could lower total U.S. healthcare spending over that period.
The gigantic numbers obscure a simpler question that needs to be debated: How do we want to pay for healthcare? The current system involves a mix of taxes and premiums paid by individuals and businesses, and it rations care to some degree by one’s ability to pay. The House Medicare-for-all bill and the proposal by Sen. Bernie Sanders (I-Vt.) are financed mainly by income-based taxes, putting more of the burden on highincome individuals and corporations.
A more fundamental question is, who should be eligible for coverage? If the system extends only to citizens and green-card holders, that would leave roughly 11 million U.S. residents uninsured, posing challenges to public health and to the hospitals and clinics that care for these patients. But offering coverage to people in the country illegally would face huge political hurdles; that’s why the authors of the ACA excluded them from Obamacare.
Then there’s the question of how much to pay for medical treatments and services. Rather than letting supply and demand set prices, a single-payer system puts the government into the position of deciding what treatments, medical devices and drugs are worth, and how much doctors, nurses and lab technicians should earn.
If the values are set too low, that could deter investment and lead to shortages. If they’re too high, rising healthcare costs will swamp the federal budget, potentially leading Congress to try to cut spending by erecting some of the same unpopular hurdles to obtaining care that insurers have used.
That leads to another crucial question: Who decides what gets covered? The House bill proposes simply to cover “medically necessary” treatments, devices and services. But what does that mean? And what would the government do when a new treatment is introduced that’s only slightly more effective but far more expensive?
The complexities involved in shifting to single-payer shouldn’t stop Congress from exploring it. Countries around the world take this approach for good reasons, after all. But getting from where we are today to the universally affordable and available healthcare system we want will take more than symbolic votes and catchy slogans.