Medicare Expansion Steps Into the Political Limelight

Democrats are running on Medicare for All—or extending the seniors’ program to the merely middle-aged—or resurrecting a ‘public option’. Republicans say Medicare expansion would mean government intrusion and inefficiency. But politics aside, how would these Medicare expansions work?

By Timothy Kelley

Sometimes it matters politically. Other times it doesn’t. But in this intensely partisan season, health care—and more specifically, Medicare—is once again very much in the game.

With Republicans struggling to defend a controversial president and signs pointing to a big opportunity in next month’s elections, Democrats are finding that health care reform is a blue-hot issue. And it’s hottest when they speak of building on a 53-year-old program that, all told, has a pretty good rep for delivering health care to the nation’s seniors. As Paige Winfield Cunningham wrote in the Washington Post’s “Health 202” blog in April, “If you want to sell Americans a bill expanding the government’s role in health care, be sure to include ‘Medicare’ in the title.”

. . . As proposed by Sen. Bernie Sanders, Medicare for All would extend coverage beyond seniors to all Americans by establishing the U.S. government as the single payer. It would eliminate private insurance with its concoction of premiums, deductibles, coinsurance, and copays. Sanders also wants to include coverage for dental and vision care. As Starr points out, it’s a bit of a misnomer because Medicare is not really a single-payer program, but one in which a third of beneficiaries now buy private coverage through Medicare Advantage plans. The proposal might be more accurately named “Medicare’s public plan for all.”

Whatever it’s called, it’s riding higher than ever. When Sanders introduced his bill in the Senate in 2013 he found no cosponsors. The version introduced in September 2017—S. 1804, the Medicare for All Act of 2017—had 16. “There’s never been as much support for single-payer as there is now,” says Sally Pipes of the conservative Pacific Research Institute—and she’s no booster but a foe who believes that “M4A”—as some insiders call it—is a terrible idea.

H.R. 676, the main Medicare for All legislation in the House, now boasts 121 cosponsors—60% of the Democratic caucus. It’s not a true companion bill to the Sanders measure. According to Edmond S. Weisbart, MD, a St. Louis family physician who chairs the Missouri chapter of the pro–single-payer group Physicians for a National Health Program, the House bill is a bit more robust in benefit design in some areas—it includes long-term care, for example—while the Senate bill is more explicit about covering reproductive choices for women. Implementation schedules also differ. Under the House measure, the new system would go “live” after two years, while the Senate bill provides for a four-year transition as different age cohorts, starting with the 55–to-64-year-olds, would migrate into the new federal coverage.

Enactment of either measure would delight Weisbart—and horrify AHIP, the health insurance trade group. “Frankly, it would be dramatically different,” says Kristine Grow, AHIP’s senior vice president of communications, “and the average American would lose a lot in a transition to single-payer.” She says it would be better to build on a current health care system that successfully fosters “quality, choice and people’s control over their own health care decisions.”

Choice? Weisbart is glad to have the topic brought up. He says 20% to 31% of today’s health care dollar goes to inefficiencies and redundancies in administration, and he invokes the not-uncommon scenario of a patient arriving at his primary care physician’s office to see a sign declaring that his insurance plan is no longer accepted—because this year its contract is no longer a worthwhile deal for the practice. “That makes me sick,” says Weisbart, arguing that true choice of doctors and hospitals would be enhanced, not diminished, in a single-payer world.

“When the government is the sole provider of anything,” counters Pipes, “there’s always inefficiency, and cost is always greater than projected.” She believes single-payer would result in long waiting lists for medical procedures and decries the Sanders program’s high cost, citing a study released in late July by the Mercatus Center at George Mason University that put M4A’s price tag over the next decade at $32.6 trillion. Yes, Mercatus is partly funded by the conservative Koch brothers, but chief author Charles Blahous is a reputable economist, she says, and his estimate is very much in line with that of a similar Urban Institute study of Sanders’ 2016 campaign proposal.