JAMA Forum: Medicare For All or Medicare For More?

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Many Democratic presidential candidates are voicing support for “Medicare for all,” a national health plan that would cover all US residents. At the same time, other candidates support proposals that sound like Medicare for all but are actually quite different and more incremental. And, just to make things even more confusing, a number of the candidates are on the record for supporting multiple proposals.

The 2020 presidential race is still in its early stages, and candidates typically do not yet have fully formed plans or white papers on policy issues. However, what the candidates are saying about health care and how they respond to controversial elements of health reform proposals, offers a glimpse into how the debate over Medicare for all might play out.

While the idea of Medicare for all has been around for decades, Sen Bernie Sanders (I, Vermont) put momentum behind it in his 2016 presidential campaign, and is doing so again this election cycle. A number of senators running for president are cosponsoring the detailed bill Sanders has introduced—Cory Booker  (D, New Jersey), Kirsten Gillibrand (D, New York), Kamala Harris (D, California), and Elizabeth Warren (D, Massachusetts).

Role of Private Insurance?
One contentious feature of Sanders’ Medicare-for-all proposed legislation would be the virtual elimination of private health insurance. Sen Sanders’ bill would prohibit insurers from selling coverage that duplicates any of the benefits in the national plan. Insurers could sell supplemental coverage, but the plan provides such a comprehensive set of benefits—and no deductibles or copays—that as a practical matter, private insurance would disappear.

Kaiser Family Foundation (KFF) polling shows that although 56% of the public supports Medicare for all, support drops to 37% if people are told that it would mean the elimination of private health insurance. There’s also confusion about what Medicare for all would actually do—even 67% of supporters believe they would still be able to keep their current health insurance plan, which would not be the case.

Although people complain all the time about their health insurance plan and about how rising deductibles have created affordability challenges, the idea of being required to give it up for a new national health plan that doesn’t yet exist understandably makes people nervous.

That political vulnerability of Medicare for all has led to a number of proposals that sound sort of like it but are less prescriptive and do not eliminate private insurance. These proposals range widely in their breadth, but they all have one thing in common: A publicly-sponsored health plan would be an option but not necessarily a requirement. These optional proposals all attract the support of about three-quarters of the public.

The narrowest proposal—cosponsored by candidates and Sens Booker, Harris, Gillibrand, and Amy Klobuchar (D, Minnesota)—would allow people aged 50 to 64 to buy into Medicare, with premium and cost-sharing subsidies for lower-income people.

A somewhat more expansive idea known as “Medicare-X” would create a Medicare-like plan to compete with private insurers in the Affordable Care Act (ACA) marketplaces for people buying their own coverage. This bill—sponsored by Sen Michael Bennet (D, Colorado), a presidential candidate as well—is also being cosponsored by Sens Booker, Harris, and Klobuchar. Lower-income people eligible for premium subsidies under the ACA could use those subsidies in Medicare. Since Medicare pays physicians and hospitals substantially lower rates than private insurers, the coverage could be less expensive, but it still may not be affordable for some who do not qualify for subsidies.

The most far-reaching “optional” Medicare proposal is “Medicare for America,” a bill that has been introduced in the House and endorsed by presidential candidate Beto O’Rourke. Many current sources of health coverage—including Medicare, Medicaid, the Child Health Insurance Program, and individually purchased insurance—would be folded into the new national health plan. Employers could continue offering private health insurance meeting certain minimum requirements, but their employees could instead choose to enroll in the national plan, with premiums scaled to income.

Former Vice President Joe Biden recently said that he does not support Medicare for all, and instead favors “making a Medicare option available to all people” and that “you’d be able to keep your own insurance if you’re satisfied.” Exactly which of the optional Medicare plans Biden supports remains to be seen.

Broad Democratic Support
There is now broad support among Democratic presidential candidates for the idea of expanding access to a public health insurance program like Medicare. This is not surprising, since 80% of Democrats support Medicare for all, according to KFF polling.

However, with the exception of Sen Sanders—who is unlikely to waver from the Medicare for all proposal he has authored—many of the candidates seem open to a variety of more incremental approaches. For example, Sen Warren has said there are “lots of paths” to universal coverage, including but not limited to Medicare for all.

It’s also important not to confuse the Democratic presidential primary with the general election, which is still a year and a half away. Any differences among the Democratic candidates on health care are dwarfed by the wide gulf that separates all of them from President Trump.

Democrats won back the House majority in the 2018 election in part on health care, criticizing President Trump and Republicans in Congress for efforts to undermine the ACA, and, in particular, protections for people with preexisting conditions.

A judge in Texas has ruled that the ACA is unconstitutional. The Trump administration, which originally took the position that only the ACA’s protections for people with preexisting conditions should be thrown out, now agrees that the entire law should be invalidated.

This case, as it works its way through the courts, may once again put President Trump on the defensive on health care and provide Democrats with a popular platform. At the same time, the Democratic presidential nominee, depending on who that is and where he or she stands on Medicare for all, could also be vulnerable to attack. Health care is shaping up once again to be a top issue in the campaign.

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About the author: Larry Levitt, MPP, is Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation. Among other duties, he is Co-Executive Director of the Kaiser Initiative on Health Reform and Private Insurance. (Image: Ted Grudzinski/AMA)

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 

 

 



Categories: ACA, Caring for the Uninsured and Underinsured, Health Policy, The JAMA Forum

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