The debate over health care can seem like an all-or-nothing proposition these days. Either you are replacing private insurance with a single, government-run “Medicare for All” program, as Sen. Bernie Sanders (I-Vt.) and his supporters would, or you’re not really transforming health care in a way that establishes it as a right rather than a privilege.
But there are other routes to universal coverage, one of which was on display Wednesday when Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) unveiled a new version of legislation they are calling “Medicare for America.”
Medicare for America envisions creating a comprehensive public insurance plan that would automatically absorb at least half the U.S. population and be open to anybody who wanted to enroll. But the measure would allow employers to keep offering private coverage, giving employees of those firms the option of sticking with a company plan. It would also preserve Medicare Advantage, the privately run version of traditional Medicare that roughly one-third of seniors currently use.
Beto O’Rourke, the former Democratic congressman from Texas now running for president, has endorsed Medicare for America by name. Other Democratic presidential candidates, such as South Bend, Indiana, Mayor Pete Buttigieg and Massachusetts Sen. Elizabeth Warren, have made statements that suggest they might prefer something like Medicare for America ― even if, as in the case of Warren, they remain co-sponsors of the Sanders bill.
Some high-profile members of the Democratic establishment are also on board, including Randi Weingarten, president of the American Federation of Teachers, and Neera Tanden, president of the Center for American Progress ― which, not coincidentally, helped to craft the bill.
The main appeal of Medicare for America is its potential to achieve much of what the Sanders proposal would, without all the disruption. But Medicare for America would still change quite a lot. “Of the public plan proposals, Medicare for America comes closest to Medicare for All,” says Karen Pollitz, senior fellow at the Henry J. Kaiser Family Foundation.
Of course, that similarity could be a strength or a weakness or maybe some of both, depending on your perspective.
A Proposal With Large Ambitions
The Affordable Care Act, or “Obamacare,” reduced the number of Americans without insurance to a record low. But millions still don’t have coverage and a big reason is that enrollment remains optional, especially now that Republicans have eliminated the financial penalty for people who decline insurance.
Medicare for America envisions automatic enrollment so that the new public program would take in everybody now on existing government plans, including Medicare and Medicaid, as well as the uninsured and people buying private coverage on their own. Employees of businesses with private benefits could accept company insurance or jump into the new public program.
Because of that automatic enrollment provision, Medicare for America could get to truly universal coverage. You can’t say the same thing about alternatives that call simply for more modest expansions of government-run insurance and subsidies that other Democrats have proposed.
And although Medicare for America wouldn’t wipe out employer coverage altogether, it would set a higher standard for what employer coverage must include ― in effect, requiring that all private plans be as comprehensive as the “gold” level insurance now available through the Affordable Care Act.
Gold plans must be generous enough to cover 80 percent of the typical person’s medical bills and most employer plans today meet that threshold. But some don’t and employers offering those plans would have to upgrade their offerings or drop them altogether.
That prospect ought to sound familiar, because it’s exactly what happened when the Affordable Care Act took effect and put in place new standards for the insurance that people buy on their own. Many insurers responded by canceling the old plans, despite President Barack Obama’s vow that Americans who liked their old insurance could keep it.
DeLauro goes out of her way to avoid repeating that promise: “God, no,” she told HuffPost. “We’ve been down that road.”
Instead, she describes these new requirements as one of the bill’s strengths. She points out that the new requirements would call for benefits that both public and private insurance frequently leave out today, including dental, vision and long-term care.
The last part is especially important for the disabled and elderly, who are likely to be wary of any changes to traditional Medicare. “This makes Medicare stronger,” she said, recalling the difficulty she faced when she was taking care of her ailing mother, who eventually died at age 103. “I was always concerned whether she was getting the right care ― and I have the resources, I’m a member of Congress. Think what it’s like for everybody else.”
Of the public plan proposals, Medicare for America comes closest to Medicare for All. Karen Pollitz, Henry J. Kaiser Family Foundation
Medicare for America would also limit health care spending, by restricting what doctors and hospitals could charge for services. On prescription drugs, Medicare for America would have the federal government negotiate directly with manufacturers and then license drugs to competitors when negotiations break down ― in effect, taking away the patent protections that allow drug companies to charge such high prices.
Medicare for America’s cost control mechanism might not be as aggressive as what the Sanders bill or its leading House counterpart, a bill from Rep. Pramila Jayapal (D-Wash.), would impose. (Sanders and Jayapal haven’t been as specific about payment levels, so it’s difficult to be sure.) But it would still mean the government directly influencing prices, as it does in pretty much every other country.
This would ignite a familiar debate over whether such control would stifle innovation or create shortages. It would also draw familiar attacks from the health care industry, which is already preparing to pounce.
“While some are framing proposals like DeLauro-Schakowsky as moderate alternatives to the sort of plan being promoted by Senator Sanders or Congresswoman Jayapal, ultimately this approach would drastically change health care in our country and be a stepping stone to a government-run health care system,” Partnership for America’s Health Care Future, an industry group, said in a statement to HuffPost.
Questions About Strategy, Not Just Substance
Under Medicare for America, people who end up in the public plan, whether by default or by choice, would pay no premiums and no out-of-pocket costs as long as their incomes were below twice the poverty line, which is roughly $50,000 for a family of four. People with higher incomes would be responsible for premiums and copayments, albeit on a sliding scale.
The coverage would be more generous than what the Affordable Care Act requires but, still, less generous than what Medicare for All would provide. In the bills from Sanders and Jayapal, nobody would pay individual premiums and nobody would pay out-of-pocket costs, regardless of their incomes, except for token copayments on some name-brand prescription drugs. Financing for the system would come entirely from taxes.
These kinds of coverage details would likely be open to negotiation if serious deliberations over legislative language ever got underway. One reason some Medicare for All proponents don’t openly contemplate compromise is that they want to push the boundaries of debate as far as they can, in the hopes of energizing supporters while avoiding preemptive, potentially unnecessary concessions. They understand that final legislation will look different and that it might even end up looking like Medicare for America.
Such an outcome would mean preserving some pretty big elements of the existing health insurance system, starting with the presence of for-profit insurers. That is no small matter. But this kind of policy evolution is typical, according to Jacob Hacker, a Yale political scientist who has written extensively on the history of social programs and worked with DeLauro and Schakowsky on their bill.
“Every country that has moved to this international standard [of universal coverage] has built on the institutions that they have already,” Hacker said Thursday. “This achieves the international standard, but in a distinctly American fashion.”