The 2020 presidential campaign is already well underway with over 20 candidates vying for the Democratic nomination. The Democrats rode a midterm election strategy emphasizing healthcare issues to much success including retaking the House of Representatives and winning many state and local races. Candidates in the Democratic presidential primary are embracing this strategy as healthcare continues to poll among the highest priority issues for voters.
While the midterms centered on the Affordable Care Act (ACA), the presidential primary is focusing on the more progressive concept of “Medicare-for-All.” Almost every candidate has at some point expressed support for “Medicare-for-All.” But what exactly is each candidate referring to when they say they support Medicare-for-All? This makes a big difference to voters.
A Kaiser poll that tracks the public’s viewpoints on healthcare revealed that the majority of Americans have a general favorability towards the broad concept of “Medicare-for-All.” But, support waned as questions were asked about the details of a Medicare-for-All plan such as eliminating private insurance and raising taxes. This poll suggests that public support for Medicare-for-All will vary depending on what shape the proposal takes.
The first and arguably the most commonly held vision of what a Medicare-for-All system looks like is that of a “single-payer” health care system. A single-payer system would establish a government-funded healthcare plan that covers essentially every medical service for every person, often without charging beneficiaries premiums or cost-sharing. Another important distinction of a single-payer system is that it could effectively get rid of all private health insurance. Senator and Democratic Presidential Candidate, Bernie Sanders’ (I-VT) “Medicare for All Act of 2019” and Representative Pramila Jayapal’s (D-WA-7) bill of the same title are examples of this kind of proposal. Single-payer iterations of Medicare-for-All would also replace Medicaid for most services. With regard to prescription drug coverage, the Government would have authority to negotiate drug prices and would establish a national drug formulary.
Of particular note, many of the proposals do not include specifics on how a single-payer system would be financed. This is a very important element to consider. A recent report from the free market-oriented Mercatus Center estimates that a single payer system could cost the federal government $32 trillion over 10 years. A single payer system represents the most drastic change to the American healthcare system, but other proposals are also being discussed on the campaign trail.
Another vision for Medicare-for-All is the establishment of a public option. Unlike a single payer system, a public option would still allow for private insurance to exist. A public health plan that is typically based on Medicare’s benefit package would compete against private health plans in the open market. This national health plan would likely charge enrollees a premium and include a cost-sharing obligation. Public option proposals in Congress include the “Keeping Health Insurance Affordable Act of 2019” from Senator Ben Cardin (D-MD) and the “Medicare-X Choice Act of 2019” from Senator Tim Kaine (D-VA) and Representative Antonio Delgado (D-NY-18).
Similar to a single payer model, the Secretary can be authorized to negotiate drug prices and establish a national formulary for prescription drugs. A public option, in theory, would aim to provide low-cost health insurance to the people who want it, while also allowing for competition and choice in the private market if one does not wish to participate in a public plan.
The final and most moderate vision of Medicare for all is the notion of “Medicare-for-More” that lowers Medicare eligibility age to perhaps age 50 or 55. This option would not structurally change how Medicare or private health insurance markets function. This is as straight forward as it reads. All US Citizens ages 50-64 have the option to enroll in Medicare if they so choose. They can also choose to remain in a different health insurance market such as the employer or ACA markets. Proposed legislation from Senator Debbie Stabenow, appropriately titled “the Medicare at 50 Act” states these exact provisions, but also authorizes the government to negotiate the prescription drug prices for Medicare.
Expanding Medicare eligibility is only one pathway to achieve these three healthcare policies. Some policy makers and think tanks have proposed expanding Medicaid eligibility to more or all people.
Despite the various legislative proposals introduced by Democrats, Republicans in Congress will continue to oppose Medicare-for-All proposals. With the Republicans in control of the Senate, Democrats will need to win more than the White House to make Medicare-for-All a reality.
Over the coming months, the debate about Medicare-for-All will increase in both frequency and substance as candidates refine and promote their stances. Democrats have varying interpretations on how Medicare-for-All would actually take shape in the United States. Because of this, it is important for people to stay informed on what politicians and pundits are referring to as “Medicare–for-All”, as one idea or interpretation may vary drastically from another.