First off, the Medicare-for-All version espoused by Vermont Senator Bernie Sanders isn’t actually an extension of Medicare, which now covers 50 million Americans, but would be phased out over four years. His bill contains provisions, such as coverage for long-term care, that aren’t covered now by the landmark health insurance plan created in 1965. Sanders is short on details of how to pay for more robust and costly benefits.
Most advocates of “Medicare-for-All” are expressing support for a single-payer system under which the federal government would assume the role of a giant, publicly funded health insurer. Sanders and others want to see expanded coverage for current Medicare enrollees as well as universal coverage. An enlarged pool of patients under a Medicare-for-All system would give government officials even more leverage to negotiate lower and more consistent pricing for medical services and prescription drugs.
Elimination of all private insurance, including insurance policies provided through employers, has been branded as “socialism” by Medicare-for-All opponents. For context, opponents said the same thing about Medicare.
Some Medicare-for-All proponents would like to see an expansion of Medicare eligibility and benefits, but not necessarily elimination of all private insurance, which provides coverage for 150 million American workers and their families.
Democrats who pushed through the Affordable Care Act (ACA) in 2010 made a similar political calculation, though they stopped short of including a “public option” that would have provided a government-sponsored health insurance plan. Instead, they opted for expanding Medicaid eligibility on a cost-sharing basis with states.
Some present-day Democrats, including House Speaker Nancy Pelosi who steered the ACA through Congress earlier this decade, still prefer an incremental approach as the logical and politically achievable next step towards universal health insurance. That might involve increased federal funding for Medicaid expansion, restoration of the mandate for everyone to have health insurance coverage or creation of some form of reinsurance pool to smooth out the cost of high-cost patients.
These variations, combined with 23 Democratic presidential candidates running around the country talking about health care while attempting to differentiate themselves from the herd, have created understandable confusion among voters. That confusion is compounded by continuing efforts by the Trump administration to take the ACA (Obamacare) off the books.
What’s clear is that some provisions of the ACA are very popular, notably preventing people with pre-existing conditions, often chronic illnesses or cancer survivors, from being denied affordable health insurance coverage. That has created a conundrum for congressional Republicans who tried unsuccessfully to repeal and replace Obamacare. Republicans express support for retain the pre-existing condition provision, yet they haven’t successfully landed on a larger platform to address health insurance access – and rising health care costs.
Beyond the debate over Medicare-for-All, health care in America is confusing. There are multiple public players (Medicare, Medicaid, Veterans Health Care, Indian Health Service, public health clinics, hospitals affiliated with public universities, public mental health clinics and public school clinics) and private players (for-profit corporations, nonprofit organizations, medical practices, medical laboratories, hospitals affiliated with private universities and integrated health care systems).
The divide between health insurance and health care delivery is a blurred line. Many private health insurance policies come with their own networks that limit choice of medical providers.
Adding to this dizzying picture are soaring drug prices, with their own cast of characters that include pharmaceutical companies, pharmacy benefit managers, self-insured corporations, foreign-based internet retail outlets and prescription drug patent attorneys.
The end result is a health care system that is costly, suffers from a lack of coordination and isn’t equitable. One report concluded, “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.”
Oregon has pioneered approaches to health care that respond to broader criticisms of the US system, or lack of a “system.” Under a federal waiver, Oregon has promoted increased in-home care for older adults and physically disabled persons that enables independent living and avoids more expensive institutional care. Oregon was among the first states to expand Medicaid eligibility, as permitted under the ACA, and has steadfastly defended that expansion despite rising costs.
Former Governor John Kitzhaber implemented coordinated care organizations serving low-income Oregonians to “bend the cost curve” through innovation and coordination. Since leaving office, Kitzhaber has pushed for investing to redress “social determinants” of health such as a lack of proper nutrition and early childhood education. Health care systems are striving to integrate physical and behavioral care to improve outcomes.
The Washington Legislature enacted this year a first-in-the-nation state-sponsored long-term care social insurance program. Under the program, Washington residents will pay 58 cents on every $100 of income, with the revenue flowing into a Long-Term Care Trust. Residents who pay into the fund for 10 years (three if a catastrophic disabling event) will be entitled to receive $100 a day up to a lifetime cap of $36,500. The money can be used for in-home care, installation of accessibility ramps, home food deliveries or transportation. The payroll tax is projected to generate $1 billion per year.
For many health care observers, actions such as Oregon’s and Washington’s are akin to bailing water out of a sinking boat. They call for a broader, more holistic approach to reform. That isn’t the same as calling for Medicare-for-All, which remains somewhere on the political spectrum between an aspiration and an abstraction.
What seems inevitable is that Americans have grown restive with gridlock as health care out-of-pocket costs and drug prices continue to rise much faster than inflation or wages. The 2018 mid-term election, which saw Democrats unseat GOP congressional incumbents and capture Republican-dominated seats, could be a bellwether of growing voter interest in tangible action on health care. Most prominent Democratic 2020 presidential candidates have apparently heard that message, which accounts for their support for Medicare-for-All or something like it that is significant and meaningful.