Defining and Establishing Goals for Medicare for All

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Although “Medicare for all” has picked up political traction, how it will materialize remains unclear.

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It is increasingly difficult to find a Democratic presidential hopeful who has not paid at least some lip service to “Medicare for all.” Indeed, ignoring this popular rhetoric would likely be political suicide for Democratic candidates.

In one poll, 73 percent of registered Democrats said they were more likely to vote for a presidential candidate who supported a Medicare for all health care policy. In response to the popularity of Medicare for all, House Democrats launched an official Medicare for All Caucus, with about 70 members.

Medicare for all, however, means many things to many people. As the fight to become the Democratic presidential candidate unfolds in 2019, it will be important to see how this term gets defined.

Many take Medicare for all to be policy shorthand for health or health care being a human right, entitling individuals to certain services and obligating the government to support access to health care.

For example, the Center for American Progress toted its proposal, Medicare Extra for All, by arguing that health care constitutes a right, as opposed to a privilege. Presidential hopeful U.S. Senator Elizabeth Warren (D-Mass.) similarly released a statement justifying her support of a Medicare for all bill by stating that “health care is a basic human right.”

Americans do not universally agree that health or health care should be a human right. But quite a few Americans support Medicare for all proposals because they believe there is some sort of right to some measure of health or health care.

The challenge with this rhetoric, however, is that health or health care has not been formally defined as a right under the U.S. Constitution or even in state jurisprudence.

On the one hand, an intrinsic right to health might offer the opportunity to try to achieve well-being or the highest attainable standard for health. In this way, individuals should be supported in pursuing the best access to care that they individually desire—which, depending on the individual, may not necessarily be complete coverage.

On the other hand, if the right to health means a right to a specific package of health care services, that may translate into policies that resemble the health care systems in Canada or the United Kingdom more than the one currently in place in the United States.

Some Democrats have proposed Medicare for all plans that look a lot like the public option originally proposed for the Patient Protection and Affordable Care Act (ACA). For example, U.S. Senators Michael Bennet (D-Colo.) and Tim Kaine (D-Va.) proposed the Medicare-X Choice Act of 2017, which would allow consumers to buy a plan that looks very similar to Medicare through the health insurance exchange markets.

Senator Debbie Stabenow (D-Mich.) similarly introduced Medicare at 50 Act that, if passed, would expand coverage through a structure similar to the public option that would be available to people between the ages of 50 and 64. Individuals would pay to get Medicare coverage, although the premium and cost-sharing subsidies currently available on the health insurance exchange markets would be accessible to Medicare buy-in enrollees.

These proposals have a strong selling point in that they do not scrap the current health care delivery and financing system while still expanding coverage to those who currently find it challenging to access affordable health care. From a regulatory perspective, these proposals essentially extend the work accomplished by the ACA. Implementing these plans would probably be a similar experience as well, with the U.S. Department of Health and Human Services issuing regulations to tweak the insurance markets to better improve access rather than radically overhauling the entire industry.

In some ways, these proposals can be framed as protecting the importance of access to health care coverage but allowing individuals to make decisions about what sort of coverage works best for them. The government should thus work to expand the opportunities and pathways that consumers might use to obtain health care coverage but not necessarily create a uniform health care experience for everyone.

The virtues of these more flexible and incremental proposals, however, can also be seen as negatives.

Because these proposals preserve the current health care system, many of the challenges surrounding administrative waste, rising costs, and affordability would remain. These challenges are similar to some of the critiques of the ACA.

Furthermore, these proposals are ultimately unsatisfying for those who have embraced the idea that health or access to health care is an unequivocal human right. Although these proposals make it easier to find affordable coverage, they do not ensure that it will always be available. They still require a significant financial commitment from consumers participating.

Other Medicare for all proposals suggest a vision for American health care that is more revolutionary in scope.

These proposals, such as U.S. Representative Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019 and U.S. Senator Bernie Sanders’s (I-Vt.) Medicare-for-All Act of 2017, look to eliminate current health care financing systems, such as the private employment-based system and Medicaid, in favor of a single-payer system that looks very similar to Medicare.

In these examples, Medicare for all does not mean simply that access to Medicare will be expanded for those interested. Instead, everyone will be required to participate in this new system within a fairly short time frame.

Some barriers to converting the American health care system to a single-payer format are obvious, such as the longstanding cultural resistance to policies that seem to derive from socialism or communism and the political challenges of raising taxes sufficiently to cover costs. But barriers to such a conversion also include significant challenges resulting from being heavily dependent the on health care economy, such as the potential loss of half a million jobs associated with the elimination of private health care insurance companies.

Additionally, converting to a single-payer system would require retraining individuals to think of themselves not as consumers with the ability to choose the right coverage for them, but as citizens with an entitlement to a certain set of services.

The more revolutionary proposals represent a notable reframing of American attitudes towards health and health care as a right. But the upheaval that scrapping our current system in favor of a single-payer system would cause is perhaps only justified by embracing health as a human right.

If health is an unequivocal human right, then the best way for the government to fulfill its obligations to its citizenry is to eliminate inefficient spending and use those savings to ensure a certain standard for all individuals. The proponents of this framing will likely not be satisfied with the less radical proposals, especially after the mixed results of the ACA expansion.

Which vision of Medicare for all will win out?

In the short term, the proposals most likely to gain traction will be those that interpret Medicare for all to mean something akin to an expansion of the Affordable Care Act and the opportunities for consumers to select their preferred health care financing vehicle. Of course, significant progress on even these less radical proposals will depend on the outcome of the 2020 elections.

In the long term, however, the notion of Medicare for all as a shorthand for a right to health and the need for a single-payer system will likely continue to gain in popularity.  Incremental change, while more practical and reasonable, rarely translates into electoral excitement.

Carmel Shachar

Carmel Shachar is the Executive Director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.

This essay is part of a 12-part series, entitled What Tomorrow Holds for U.S. Health Care.