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: Exit polls on Nov. 6 found that healthcare was the leading issue for those casting ballots, and 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 by a president who campaigned against it (with characteristic hyperbole) in the weeks leading up to the November election. There could be political consequences too: Forcing newly elected House members from formerly Republican-held districts in the Midwest to take a tough vote on a government-run health insurance system could usher Democrats back into the House minority.
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 more detailed proposal by Sen. Bernie Sanders (I-Vt.) are financed mainly by income-based taxes, putting more of the burden on high-income individuals and corporations. Other countries with single-payer systems take a variety of approaches, including requiring some premiums and out-of-pocket costs to reduce the burden on government budgets (and taxpayers) and curb excessive demand for care.
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 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 of treatments and services. If they’re too high, rising healthcare costs will swamp the federal budget, potentially leading Congress to try to cut spending by doing some of the same unpopular things that insurers have done, such as making patients jump through more hoops before obtaining expensive treatments.
That leads to another crucial question: Who decides what treatments get 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?
Policymakers need not just air these issues, but reach consensus on them. The GOP’s incessant bashing of the ACA is instructive here. Having no investment in the measure, Republicans continually sought to repeal or undermine the law instead of adjusting and improving it as problems emerged. The result was much higher increases and dwindling competition. Expanding Medicare with no Republican votes would be setting the stage for a similarly dysfunctional rollout.