Medicare for all – why supporters can’t agree what it should mean

Why We Wrote This

American ideas about what universal health coverage should look like aren’t exactly universal. Between the dickering over “single payer” versus “public option” models lies a deeper debate about how Americans value health care.

J. Scott Applewhite/AP
Ady Barkan, a high-profile health care activist who has been diagnosed with amyotrophic lateral sclerosis, testifies before the House Rules Committee about a ‘Medicare for All’ bill in Washington, April 30.

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American politicians have proposed universal coverage as far back as 1912, when Theodore Roosevelt supported it during his unsuccessful third-party campaign to regain the presidency. Today, that goal is rising again.

Democratic presidential candidates are supporting various plans, often under the name “Medicare for All.” And they’re drawing energy from public opinion. Polls have found growing public concern about health care, as costs keep rising and the United States remains alone among advanced economies in lacking universal insurance.

For supporters, a key choice is whether to seek a “single payer” system that would centralize administration in the government, or to add a “public option” alongside other insurance plans. Some candidates say the first will be most efficient. Others support the second as a less-wrenching change, and as a system that can better leverage competition among providers.

“This is a values conversation and decision at a root level. How much do you want everybody to be treated the same?” says Linda Blumberg, a health policy expert at the Urban Institute. “We have a structure that with its gaps and shortcomings can be built upon and improved.”

When the House Rules Committee recently took up a controversial topic – shifting U.S. health care onto the shoulders of government as a “single payer” – the voice of one witness seemed loudest precisely because he had none. Due to illness, activist Ady Barkan was unable to speak to the committee. Instead his typed responses, delivered to the room by a monotone synthetic voice, told of his battles with insurance companies as he seeks both medical care and time with his wife and young son.

“If I couldn’t use GoFundMe, I would probably start by asking my parents to start spending down their retirement savings, then we would go hat in hand to friends. Nobody dealing with a serious illness should have to do either of these things,” he said. “We should instead have a rational, fair, comprehensive social safety net that actually catches us when we fall.”

At the April 30 hearing, Mr. Barkan was among several witnesses and lawmakers who urged the case for a single-payer system.

It would be a radical break from the status quo. Supporters say that’s exactly the point, after what they see as years of inaction and half measures, and with more than 27 million Americans lacking health insurance. Critics say there are reasons this idea hasn’t flown in the United States before and why it shouldn’t fly now.

But look beneath the surface of the “Medicare for All” debate, and the real story may be about the revival of a basic ideal: the goal of universal health insurance – whether it’s called a human right, as Mr. Barkan and some Democratic presidential candidates do, or is just something that a rich nation can afford for its citizens.

The goal is neither new nor, historically, exclusive to the Democratic Party. In a 2015 Harris poll, 84% of Americans agreed it’s “a moral issue” to have “a system that ensures that sick people get the care they need.” That included 75% of Republicans.

Yet for many, that view doesn’t automatically mean the government should be the sole buyer of insurance. Even among Democratic voters, there are concerns about how to both control costs and avoid rationing of care in such a system. 

“All the candidates are interested in improving affordability and access [to health care] relative to what we have today,” says Linda Blumberg, an expert on health policy at the Urban Institute in Washington. But “we’re a pretty incremental country. We don’t move too fast. We don’t like disruption, and we generally don’t like to be told what to do.”

A key issue for voters

Driving the discussion: Health care has risen in importance for voters in recent years, judging by exit polls of voters after they cast ballots. A key reason is financial, with the cost of health care continuing to rise as a share of household budgets.

For many, it’s also that, even as “Obamacare” has grown more accepted as a vehicle for expanding access to care, Republicans have sought to repeal it without having a clear replacement plan.

“The attempt to repeal the Affordable Care Act really scared the American people,” says Topher Spiro, a health-policy specialist at the liberal Center for American Progress in Washington. “When you try to take something away, it tends to be highly motivating.”

Support for a single-payer system seems to have risen over the past year or so. Yet, even as the issue galvanizes the political left, Democratic candidates and lawmakers are far from united over what Medicare for All means.

To some people, this means making a government health plan the only one available – a true single-payer system with the advantages of universal coverage and economies of scale. Supporters say costs for care would fall as government uses its leverage to set lower prices with doctors and hospitals.

Critics worry that costs would instead rise as the government seeks to provide more benefits to more people.

This pros-and-cons debate – outlined both in a report that Ms. Blumberg co-authored and in a Congressional Budget Office analysis – has erupted along partisan lines, as Republicans question the ability of government to vastly expand its role over a sector that currently represents nearly one-fifth of U.S. economic activity.

“I would say that anybody believes that a government-run health care system provides better health care at lower prices, I got some land that’s underwater I need to sell you for high-rise condos,” Rep. Ralph Norman, a Republican from South Carolina, said on May 22 at a second House hearing on the issue.

But also at that hearing, Democratic Rep. Pramila Jayapal of Washington state noted that nations with single-payer systems provide universal coverage while spending less on health care than the U.S. does.

Less radical change?

Until Republicans offer a rival plan of their own, the big battle is really among Democrats themselves. Some presidential contenders argue that the goal of universal coverage can be better attained with less radical change, such as creating a “public option.”

In fact, while the U.S. stands alone among advanced economies in not offering universal coverage, the models in those other nations are varied and far from one-size-fits-all. That idea may resonate with Americans who tend to value choices – whether of doctors, of insurance plans, or of approaches to care, such as for conditions that may have no known medical cure.

Polls suggest that many Americans don't want their employer-based plans – or the current version of Medicare – to disappear.

“One doesn’t necessarily have to go to a single-payer system,” says Sara Collins, an expert at the Commonwealth Fund in New York, which supports the goal of universal coverage. “One can build on the current system. I think the overall [public] concern is what people are paying, and the fact that millions of people are still uninsured.”

Rep. Seth Moulton, a Massachusetts Democrat, is among the presidential candidates endorsing the idea of a public option competing with private insurance offerings.

“I’ve seen the good, the bad, and the ugly of single-payer health care,” said Mr. Moulton, who as a military veteran has relied on Veterans Affairs hospitals. While praising the VA for negotiating lower prescription drug prices, he described challenges such as veterans waiting for care or having their records mixed up. 

“Competition is good,” he said. “And just like we have options for delivering packages, I think we should have options for delivering health care.”

A values conversation

A trend of consolidation in the industry has left many hospitals as near-monopolies in areas they serve. Some experts see the current high costs in the U.S. as an inherently vexing challenge, no matter what path the nation takes. 

For instance, if policymakers tried to extend current Medicare pricing to all Americans, that would be asking hospitals to take an instant pay cut, since Medicare currently doesn’t pay them as much as private insurers do.

“I think there would probably be almost immediate tremendous pressure” upward on prices, says Ed Dolan, an economist at the Niskanen Center, a free-market-oriented think tank in Washington.

Pointing to the Netherlands, which blends taxpayer funding with competing private insurance providers, he says “it seems a lot easier to move the American system into that model” than to migrate toward a more government-centered system such as Britain’s. 

Whatever the details, some advocates say what’s most vital is that Americans shouldn’t have to worry about going without health care, or about facing financially ruinous choices.

American politicians have proposed universal coverage as far back as 1912, when former President Theodore Roosevelt supported it as part of his unsuccessful third-party campaign for the White House.

Congress sought to move toward that goal by creating Medicare for the elderly and Medicaid for low-income Americans in the 1960s. The Affordable Care Act in 2010 marked a major step beyond that, expanding Medicaid and setting up marketplaces for other Americans to shop for plans with government subsidies. 

Ms. Blumberg at the Urban Institute welcomes the way the Democratic presidential campaign promises to nudge candidates toward more detailed proposals, and perhaps toward answers on some of the tough challenges.

“This is a values conversation and decision at a root level. How much do you want everybody to be treated the same?” Ms. Blumberg says. And she adds: “We have a structure that with its gaps and shortcomings can be built upon and improved.”

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