In his column yesterday, Paul Krugman reminded us that there are many possible solutions to our health care mess and that the Democratic Party seems to be moving toward two possibilities.
On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.
On the other side, there’s “Medicare for America,” originally a proposal from the Center for American Progress, now embodied in legislation.
The difference is that Medicare for America would allow people to keep employee-based insurance if they (and their employers) want that. Buying into Medicare would be a voluntary option, with substantial subsidies provided for lower- and middle-income people.
My concern is that a lot of people I bump into on social media seem fixated on Medicare for All as the only way to go, and any other approach is selling out. In many cases I can tell that people making these pronouncements are using “Medicare for All” as a synonym for “universal health care as a right” without really understanding that Medicare for All is just one of many roads to the same goal.
These days, most people on the left are very aware that the United States is the only industrialized democracy that doesn’t have a taxpayer-supported system providing at least basicc health care to all citizens. What has escaped the notice of many is that the many different countries have developed many different way to approach this. The French system is different from the German system is different from the Japanese system is different from the UK’s National Health Service system, etc.
Many countries have mixed public and private systems. The very highly rated Australian health care system, for example, provides a single-payer system to cover many medical services but encourages people to get private insurance also, often subsidized, for more comprehensive coverage. You can read about it here. The Commonweal Fund gives the Australian system a very high rating for providing good care; it’s also one of the most cost-effective systems on our planet.
I’m not saying that this is how the U.S. should go; I’m just pointing out that there are many ways to provide universal health care. Countries with only a single-payer system providing all health care are unusual. Most countries have worked out some kind of mixed public and private system. Switzerland’s system is something like Obamacare on steroids. The British National Health Service features government-owned hospitals staffed with government-employed doctors. And so on. You can compare the health care services of several countries from this page.
Every two years the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands.
What’s remarkable about those top three is that they have radically different systems. Britain has true socialized medicine — direct government provision of health care. Australia has single-payer — it’s basically Bernie down under. But the Dutch rely on private insurance companies — heavily regulated, with lots of subsidies, but looking more like a better-funded version of Obamacare than like Medicare for All. And the Netherlands actually tops the Commonwealth Fund rankings.
It’s a shame we haven’t been allowed to have a rational discussion about national health care systems and what might work best for us without right-wing whackjobs screaming over everyone about death panels and gulags. But that’s the world we live in.
Krugman argues that the system he’d prefer to go with is the one most likely to actually get passed in Congress and enacted into law. And a lot of people think that the Medicare for America plan would be an easier sell.
As you may know, almost every Democrat running for president has said he or she supports Medicare-for-all, but most of them (with the exception of Sen. Bernie Sanders, who has been proposing a single-payer plan for years) have been vague about what that might mean. Maybe private insurance will be eliminated, or maybe not; maybe people will continue to get coverage through their employers, or maybe not. They will all presumably present specific plans eventually, but they haven’t yet.
What they are doing is circling closer and closer to something that doesn’t yet have a name, but which I’ll call “Medicare For Anyone.” The fundamental difference between that and Medicare-for-all is that instead of eliminating (or minimizing) private insurance and putting everyone into the same pool, it would open up Medicare or something like it to anyone who wants it.
In most of the variations that have been proposed, large numbers of Americans (newborns, people with low incomes, the uninsured) are automatically enrolled to make sure they’re covered. Employers can choose to stay with the insurance they have, or put their employees into the government plan. It’s paid for through a combination of taxes and premiums, with low-income people paying nothing and premiums rising with income.
For the moment I won’t get too deep into the policy details. But if you’re looking for a full version of it, there’s a proposal from Reps. Rosa DeLauro and Jan Schakowsky called “Medicare for America” that is probably what most Democratic candidates will either specifically endorse or which will be very similar to what they present.
But if you want to sum it up in the most simplified form, this kind of proposal is like Medicare-for-all, except instead of everyone being put into Medicare, there will still be private insurance plans that people can stay with if they want to. If the policy heart of it is that everyone gets insured, the political heart is that it’s voluntary.
I suspect that over time the employee-based insurance would fade away and pretty much everyone would be in the single-payer system. And like Krugman, I also believe that selling the Medicare for America plan to the American people would be a lower mountain to climb than achieving Medicare for All.
However, I fear that even if most of the Democratic Party gets behind it, the plan will be undermined by people on the Left who are suspicious of anything that doesn’t have the Medicare for All label. If that gets in the way of passing something, that would be a damn shame.
For that matter, if Obamacare could be updated to make it more like the systems in Switzerland and the Netherlands, that wouldn’t be absolutely terrible. I’d prefer one of the Medicare-based approaches, though.