There can be many paths up a mountain. That’s true even of some of the tallest peaks in our national political landscape — most prominently, health care. But not every route is necessarily a good one. What looks like the shortest may be too steep, stranding its followers where they started.
Medicare for All, a lodestar of the Democratic Party’s most liberal presidential candidates, is one of those deceptively simple pathways. It would be the most effective, economical approach to universal coverage, which is what the national goal should be.
Polls imply, however, that Medicare for All may be much too rocky a road for the current state of American politics. The candidates and the public need to keep their minds open to alternatives, such as the public option that didn’t make it into Obamacare nine years ago.
Under that option, the government would offer insurance to people too young for Medicare and not poor enough for Medicaid where commercial insurance plans are too few or too costly. In effect, it would not be Medicare for all, but Medicare for those who need it. It would not be the most efficient reform and it would accomplish less for cost control, but it would be a significant improvement.
The health insurance industry wouldn’t like it any more now than it did in 2010, when it ganged up to block a public option. But the industry would like even less — and resist even harder — the Bernie Sanders and Elizabeth Warren proposals to do away with private coverage altogether. It might be time to make the companies an offer they can’t refuse.
Polling shows that Medicare for All appeals to the public, but support drops far off when people are asked about having to give up their own health insurance. That political reality stands in the way of an all-or-nothing approach.
Strange to say, the force most likely to bring about Medicare for All happens at the moment to be not the liberal Democrats advocating it, but the Republicans who are still seeking to destroy the Affordable Care Act.
They could succeed in a case to be argued before the Fifth U.S. Circuit Court of Appeals in New Orleans. It’s the review of a decision from Texas, where a cabal of Republican state attorneys general, including Florida’s, went judge-shopping and found what they wanted in U.S. District Judge Reed O’Connor.
Appointed by George W. Bush, O’Connor has already ruled against the Obama administration in two major cases. In December, he held the entire Affordable Care Act unconstitutional because Congress and President Trump had wiped out the tax on people who choose to remain uninsured. The tax was the hook on which Chief Justice John Roberts had cast the deciding vote to uphold Obamacare.
What makes O’Connor’s widely derided decision so dangerous is the Trump administration’s refusal to defend any part of the law and to ask instead that the appeals court strike it down entirely. The Justice Department also argues that the House of Representatives and 20 mostly Democratic states that came into the case have no standing to defend the law. Should O’Connor rule they lack standing, Obamacare would be left defenseless there and in the Supreme Court.
A decision against the law would immediately terminate coverage for 21 million people who are enrolled under its provisions. It also would threaten millions more with being dropped or denied coverage on account of such pre-existing conditions as diabetes and pregnancy, which Obamacare requires all insurance to cover. Adult children could be kicked off their parents’ plans on turning 18. Medicaid expansion would be overturned, forcing 36 states to make millions more people uninsured or take on the entire cost themselves.
Donald Trump and other Republicans who relish such an outcome should be careful of what they’re wishing for. Health care would become the dominant issue in the campaigns for president and Congress, and boost Democratic prospects across the board.
With the slate wiped bare, Medicare for All would become the simplest option. As Medicare is financed almost entirely by taxes, it would clearly be constitutional under Roberts’s earlier opinion.
An estimated 1.7 million Floridians are enrolled in private insurance plans through Obamacare exchanges. Attorney General Ashley Moody serves them badly by perpetuating her predecessor’s hyper-partisan decision to join in attacking the law.
Medicare for All would cost no more, and most likely less, than the $3.5 trillion that the nation spent from all sources for health care in 2017. That was $10,739 per person, significantly more than in other industrialized nations. It equaled 17.2% of gross domestic product. The comparable figure in France is 11.5 percent.
As Sanders says, workers and employers would pay more in taxes, but less out of pocket. Administrative costs would come down deeply because private insurance companies take up to 18% of every premium dollar for overhead. That’s nine times Medicare’s rate.
But independent fact-checkers say Sanders’s $500 billion savings estimate is probably too high. There’s also no sure way to predict hospital charges if they could no longer bill private patients. A RAND study released in May found hospitals charge the privately insured 2.4 times what they’re allowed to bill Medicare. The hospital industry claims that’s because Medicare and Medicaid don’t pay enough.
That objection and the strength of the lobby behind it has already cut into Washington State’s new public option law, the nation’s first. Sponsors wanted to set reimbursement levels at Medicare rates, but industry pressure pushed them higher.
The same outcome would be likely in Congress, so no one can say what Medicare for All would actually cost or how much it would save.
What is certain is that the United States would no longer be the only wealthy nation where health care is treated as a privilege for all who can afford it, rather than as a human right for all. That is as much a moral issue as an economic one.
The United States stands alone among the wealthy nations in lacking universal health care. The others spend much less and get better results. Methods vary. In some, like Canada, government is the single-payer. Others, including the Netherlands, Germany, Japan and Switzerland, rely on commercial health insurance companies, but regulate them carefully and allow citizens freedom of choice. France is essentially a single-payer country, but people need supplemental coverage such as what Medicare enrollees purchase in the United States.
With more than 30 million of our people still uninsured, the issue should not be the urgency of universal coverage, but only how to move toward that goal. To retreat instead, as the Republican lawsuit proposes, should be repugnant to anyone with a conscience.