Is ‘Medicare for All’ Possible Anytime Soon?

The 2016 presidential race is shaping up to be unlike any other in history.

It’s been compared to a WWF tournament and has bewildered and tantalized the American public. As with previous presidential elections, however, healthcare is a dominant issue. A recent Gallup poll of 1,549 adults found that 58% of respondents polled favored a single-payer, federally funded healthcare system, sometimes referred to as “Medicare for All.” This is the system proposed by candidate Bernie Sanders

The survey described the three major candidates’ healthcare policies without attaching candidate names to them. A slim majority (51%) favored repealing the Affordable Care Act (ACA) (the position of Donald Trump), with 48% favoring keeping the ACA (as proposed by Hillary Clinton). So, what would Medicare for All mean, and how on earth would we get there from where we are now? Here’s some of what voters and candidates are saying.

What People Like About the Idea of Medicare for All

While Sanders supporters are the strongest backers of Medicare for All single-payer healthcare, there are also non-Sanders supporters in favor of such a plan. They consider the advantages to be obvious:

• Most other developed countries have single-payer systems
• It theoretically puts government in a position to contain costs
• It removes the profit motive from healthcare
• It builds on Medicare, the enormously popular single-payer program for people over 65

In fact, the popularity of Medicare is one reason the nickname “Medicare for All” has been used heavily – it has a positive connotation with many people. The fact that the healthcare system in the US is a for-profit enterprise rubs many people the wrong way, as do the enormous costs of insurance CEO salaries and inefficient billing processes. Healthcare in the US, say supporters of a single-payer system, costs considerably more than many countries in Europe with single-payer systems, while not delivering healthcare that’s any better than what those countries have.

Fears About Medicare for All

There are many fears associated with the creation of a Medicare for All type system too. For one thing, many people simply don’t trust the federal government’s involvement in healthcare. Many Republicans take the angle that the ACA is disastrous and needs to be repealed and replaced with a more market-oriented system. More conservative Democrats tend to be OK with the ACA, and some like the idea of Medicare being expanded to more people.

Other worries associated with a single-payer system include the closing of many rural hospitals which already operate on razor-thin margins, and fears of single-payer healthcare services being given to undocumented immigrants. Conflicts over reproductive services in a publicly run program would almost certainly arise, touching on the always-inflammatory debate over abortion and other reproductive rights.

Hillary Clinton’s Proposal: Medicare for More

Mrs. Clinton has floated the idea of allowing people over age 50 or 55 to purchase Medicare plans. Currently, only people over age 65, some of their dependents, and people with specific health conditions like end-stage renal disease are allowed to enroll in Medicare. So, instead of “Medicare for All,” Clinton’s plan could be seen as “Medicare for More.”

What might such a plan mean for the healthcare landscape in the US? Currently there are around 13 million people aged 50 to 65 who either buy private insurance through the ACA or who are uninsured. These 13 million are largely made up of people without affordable employer-sponsored coverage, and these are the ones Clinton proposes offering Medicare coverage to. For relatively healthy 50- to 65-year-olds, it could be a good choice, but Medicare also has disadvantages, like 20% cost-sharing and no lifetime limit on out-of-pocket expenditures. This could bode ill for those with low income, but who don’t qualify for Medicaid in their states. And, of course, if the Medicaid expansion debate is anything to go by, there would certainly be a political fight over expansion of Medicare.

Donald Trump: Conflicting Statements on Healthcare Policy

Mr. Trump started out supporting the ACA mandate concept (where most people have to buy insurance or face a hefty tax penalty), but has backed away from that concept more recently. He also suggests that people who purchase insurance on individual markets could get tax deductions for their premiums, but this tax break would mean little to people with incomes low enough to pay little or no federal income tax. The Trump campaign says these people, however, would be eligible for Medicaid, which he would like to turn into block grants to state governments.

Though many Republicans have expressed frustration at the unusual succotash of policies that a Trump Administration would supposedly bring, Trump himself isn’t worried, because he believes his stances play up his “outsider” status. Exactly who is advising Trump on healthcare policy reform has not been specified, other than that they are “very prominent people.”

How Do Doctors Feel About a Single-Payer System?

More than 2,200 US physicians have called for sweeping change in healthcare coverage, signing on to a proposal published in the American Journal of Public Health‘s May 5 issue. This proposal calls for a single-payer national program for all Americans. They believe the private insurance industry is too expensive and inefficient, and are interested in something akin to what Canada has, which is its own version of Medicare for All. In an ironic twist, however, Canada is currently embroiled in a legal battle that could make the insurance landscape there open to a multi-payer system like what the US currently has.

The US spends around 18% of its healthcare dollars on billing, insurance, and other administrative costs, while Canada spends just 2% of its healthcare dollars on administrative tasks. Administrative costs for hospitals are lowest in countries like Canada with single-payer systems, and highest in countries with multi-payer systems, such as the US, the Netherlands, and the UK, whose National Health Services (NHS) is supplemented by the availability of private insurance plans.

Addressing Major Drivers of Health Cost Inflation in the US

The ACA has had its challenges expanding coverage and containing costs, and according to Dr. Marcia Angell of Harvard Medical School and former editor-in-chief of the New England Journal of Medicine, there are two critical factors that make the US healthcare system the most expensive in the world and perhaps the most difficult within which to contain costs:

• Huge inefficiencies in the private insurance industry mean that it flourishes based on refusing coverage and denying claims. These companies also have high profits, high marketing expenses, and other high overhead expenses. Medicare’s overhead is around 2%, by contrast.
• A fee-for-service reimbursement paradigm means providers have incentives to perform as many highly-reimbursed tests and procedures as possible.

In many ways, insurance and providers are at cross purposes, and healthcare consumers end up paying for it.

Other Healthcare Issues Politicians Should Be Talking About

Kaiser Health News, for one, says that policy discussions surrounding the American healthcare system don’t go far enough. Five issues the organization says should be on the table, particularly in an election year, are:

• Out-of-pocket spending
• Drug development and drug prices
• Long-term care costs for the elderly and disabled
• Medicare coping with the retirement of the baby boom generation
• Dental care, which is out of reach for many Americans, including Medicaid patients

So in addition to the single-payer vs. multi-payer conversation, American voters should also pay attention to what their local, state, and national candidates have to say about these other healthcare related issues before going to the polls.

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