Democrats with 2021 presidential aspirations are courting the party's increasingly influential progressive wing and staking out ambitious policy platforms.
Front and center are three words: Medicare. For. All.
That simple phrase is loaded with political baggage, and frequently accompanied by vague promises and sophisticated jargon. Different candidates use it to focus on different voter blocs, resulting in sometimes divergent, even contradictory ideas.
“People are referring to this as a goal, as a commitment, like a value over a specific program,” said Celinda Lake, a Democratic pollster.
In championing “Medicare-for-all,” politicians often help with an over-all idea: universal healthcare, or some system in which everyone is able to afford health care. However their visions for achieving that vary wildly.
Sometimes Medicare-for-all is supposed to promise a single-payer healthcare system -meaning most people are included in one, often government-run health plan. In some cases, politicians who say they support “for all” actually mean “for more.”
Every proposal brings its own trade-offs.
“There's not merely one easy response to exactly what a single-payer system would do to the United States,” said Jodi Liu, an economist in the nonprofit Rand Corp. who studies single-payer proposals. “What happens depends on how that change has been designed, and just how it's being implemented.”
Here's a primer around the Medicare-for-all debate. Keep it in your back pocket: This argument won't be disappearing in the near future.
Isn't Medicare-for-all what it seems like? Medicare for everybody?
Not quite. But additionally, kind of.
Politicians referring to Medicare-for-all typically mean one of two things. It's whether specific proposal in which every American is included by the same, single health plan, or even the general idea that anyone has the choice to get health care through Medicare.
The first understanding is outlined inside a bill from Sen. Bernie Sanders (I-Vt.). Co-sponsors include Senate Democrats like Elizabeth Warren of Massachusetts, Kamala Harris of California, Cory Booker of New Jersey, Kirsten Gillibrand of recent York and Jeff Merkley of Oregon. Have the ability to either announced a run for president or indicated they are strongly considering one.
And they are talking about this around the campaign trail.
Sanders' bill would outlaw private insurance where it competes with the public plan and alter Medicare substantially by eliminating copays and other cost sharing, while expanding the program to cover long-term care, prescription medications, dental hygiene and vision. (As the bill is written, it's difficult to see what can be left for private intends to cover.)
The program would phase in over four years and canopy every American. And it's important to note that, though many countries run a single-payer system, none offers all those “expanded” benefits because the expense could be enormous. Also, many single-payer programs require a degree of cost sharing, involving small copayments or deductibles.
In other cases, the “Medicare-for-all” phrase has been repurposed.
The midterms saw a wave of Democrats campaigning onto it. But beyond the buzzwords, what they were actually referring to was lowering Medicare's eligibility age or giving people the choice to purchase in or join this program. This would leave the private insurance industry intact. It would also preserve Medicare Advantage, in which the government pays private companies to run Medicare plans.
For many voters, it's less about granular details and much more about the principle, Lake suggested: “The highest level of support happens when you talk about [Medicare-for-all] generally.”
So are Democrats saying we ought to eliminate private insurance?
Democrats who have signed on to Sanders' bill have endorsed legislation that would outlaw almost all private health insurance. That's controversial.
Private insurance covers the largest share – 56 percent in 2021 – of Americans. And voters are often afraid of losing what they've if it's uncertain they'll get something better as a swap. Just ask then-President Barack Obama, whose Affordable Care Act-related promise that “if you like your plan, you can keep it” sparked sharp backlash after proving untrue.
This gets at a key question: Can Medicare-for-all advocates convince voters they'll replace their own health plans with something better?
After all, most Americans say they support Medicare-for-all. However, many of the same polls indicate that many individuals with employer-sponsored insurance think their coverage could be unsusceptible to the switch. That's false.
Critics also say eliminating private insurance could gut a major sector of the health economy. By December 2021, private coverage of health was directly accountable for almost 540,000 jobs, according to the Bls. Economists note, though, that predicting the number of jobs would go away – versus the number of might be absorbed through the new system – is difficult, as is projecting any macroeconomic impact.
The magnitude of these a big change underscores why some Democrats are trying to tread lightly for anxiety about land mines.
When probed on Medicare-for-all, Harris said she supported eliminating private insurance – whilst saying she'd, within the interim, back other bills that expand use of healthcare. Warren, in a televised interview, sidestepped specifics altogether. And Booker told reporters he would not outlaw private health care, noting that lots of other countries have achieved universal coverage without taking this task.
For example, Germany has universal health care but leaves private insurance intact, while heavily controlling the industry and requiring plans be not-for-profit.
So what other options are Democrats talking about?
Voters is deserving of acquainted with two other ideas: lowering Medicare's eligibility age, and also the “public option,” through either a Medicare or Medicaid buy-in.
These concepts are decidedly not Medicare-for-all – think “Medicare for more” or “Medicaid for more.”
Lowering the eligibility age loops more and more people into the current system and is seen by advocates as a potential step toward single-payer, said Alex Lawson, head from the left-leaning Social Security Works, who has tried drafting Medicare-for-all legislation.
The public option lets people purchase coverage through Medicare or Medicaid. It has attracted criticism from Democrats aligned using the Sanders wing, who argue it's settling for less.
Senate Democrats have introduced bills advancing such ideas – including Merkley, who pushed a Medicare-based public choice to let individuals and employers buy Medicare coverage, while also attaching himself to Sanders' measure. An offer from Sens. Tim Kaine (D-Va.) and Michael Bennet (D-Colo.) would extend that option only to individuals. (Bennet is also purportedly weighing a 2021 bid.)
Said Liu, the economist: “The devil is in the details.”
Shouldn't we consider who'd pay? Would this make things better?
Any health system includes trade-offs, winners and losers. Would Medicare-for-all mean higher taxes? Probably. Opponents would certainly express it does, a disagreement that, polling shows, weakens support.
Would the average person pay more? That's hard to know.
People wouldn't pay the things they currently do for health insurance, an outlay that's only getting good expensive. They'd also likely have more generous health coverage. And lawmakers are pitching many other bills – see Warren's wealth tax, Sanders' estate tax or the 70 % marginal tax around the wealthy touted by Rep. Alexandria Ocasio-Cortez (D-N.Y.) – that backers argue would generate revenue to pay for something similar to Medicare-for-all.
Perhaps higher, a minimum of politically, are the implications for healthcare stakeholders like hospitals, insurers and drugmakers. All are in position to lose under single-payer, especially if it's accustomed to bring down healthcare costs. They're already working to make their opposition felt. (Having said that, opposition from the health industry is not universal.)
When Democrats say they need Medicare-for-all, then can they mean single-payer?
There is a large amount of brouhaha on this.
Take the backlash when Harris, after backing single-payer, said she also supported “Medicare-” and “Medicaid for more”-type policies. Her spokesman compared that to “wanting a burrito” while being prepared to accept tacos in the meantime.
Of course, Harris isn't the only one to straddle those plans. Merkley, Gillibrand, Booker and Warren have take their names to multiple health reform bills. So, actually, has Sanders, who dicated to support, among other bills, the Affordable Care Act – decidedly not single-payer.
So are Democrats wavering? Is saying “Medicare-for-all,” or even single-payer, a hook to win votes, or perhaps a bargaining strategy to get a public option instead?
It just isn't that easy.
“None people can see in to the hearts of anybody. And it is not a low-bar aspect to sponsor an invoice,” said Lawson of Social Security Works. In a presidential campaign, though, “people may wish to hedge.”
But, he added, Medicare-for-all's popularity – even while an idea – shows something significant.
“There is a consensus that the current system needs to fundamentally transform,” he said. “There's a commitment to do that. Only then do we need to argue out the details.”